Neck Masses: Differential Diagnosis Indian Medical PG Practice Questions and MCQs
Practice Indian Medical PG questions for Neck Masses: Differential Diagnosis. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Neck Masses: Differential Diagnosis Indian Medical PG Question 1: Regarding parotid neoplasms, the false statement is
- A. FNA has low sensitivity and specificity in diagnosing parotid neoplasms (Correct Answer)
- B. Enucleation leads to recurrence
- C. Pain may be a pointer for malignancy
- D. Deep lobe tumors can present with trismus as early presentation
Neck Masses: Differential Diagnosis Explanation: ***FNA has low sensitivity and specificity in diagnosing parotid neoplasms***
- **Fine needle aspiration (FNA)** is actually a highly sensitive and specific diagnostic tool for evaluating parotid gland masses, typically achieving sensitivity and specificity rates of over 90%.
- It helps in distinguishing between inflammatory, benign, and malignant lesions with good accuracy, guiding subsequent management.
- **This is the FALSE statement** - FNA actually has HIGH sensitivity and specificity.
*Deep lobe tumors can present with trismus as early presentation*
- **Trismus** (difficulty opening the mouth) is associated with **deep lobe parotid tumors** or tumors that invade adjacent masticator muscles or the pterygoid plates.
- Deep lobe tumors can cause trismus when they extend toward or compress the muscles of mastication.
- **This is a TRUE statement** - deep lobe involvement can cause trismus.
*Enucleation leads to recurrence*
- **Enucleation**, which involves simply shelling out the tumor without a cuff of healthy tissue, is associated with a significantly higher recurrence rate for benign parotid tumors, especially **pleomorphic adenomas** (20-45% recurrence).
- The standard surgical approach for benign parotid tumors is **superficial parotidectomy** or partial parotidectomy to ensure clear margins and reduce recurrence.
- **This is a TRUE statement** - enucleation does increase recurrence risk.
*Pain may be a pointer for malignancy*
- **Pain** associated with a parotid mass is a concerning symptom and often indicates **malignancy**, especially if it is persistent and progressive.
- Benign parotid tumors are typically painless and slow-growing unless they become very large or inflamed.
- **This is a TRUE statement** - pain is a red flag for malignancy.
Neck Masses: Differential Diagnosis Indian Medical PG Question 2: A 23-year-old male patient presents with midline swelling in the neck. The swelling moves with deglutition and protrusion of the tongue. What is the likely diagnosis?
- A. Brachial cyst
- B. Thyroglossal cyst (Correct Answer)
- C. Plunging ranula
- D. Dermoid cyst
Neck Masses: Differential Diagnosis Explanation: ***Thyroglossal cyst***
- A **thyroglossal cyst** is a congenital anomaly that arises from the persistent **thyroglossal duct**, a remnant of the thyroid's embryologic descent.
- Its classic diagnostic feature is its movement with **deglutition** (due to attachment to the hyoid bone, which moves during swallowing) and **protrusion of the tongue** (as the thyroglossal duct is connected to the base of the tongue).
*Brachial cyst*
- A **brachial cyst** is a congenital neck mass that typically presents as a lateral neck swelling, often located along the anterior border of the **sternocleidomastoid muscle**.
- Unlike a thyroglossal cyst, it does not typically move with **deglutition** or **tongue protrusion**.
*Plunging ranula*
- A **plunging ranula** is a type of mucocele that arises from the **sublingual gland** and extends below the mylohyoid muscle into the neck.
- It presents as a cervical mass but is typically located in the floor of the mouth or submandibular region and does not move with **deglutition** or **tongue protrusion**.
*Dermoid cyst*
- A **dermoid cyst** is a congenital cyst that can occur anywhere on the body, including the head and neck, often presenting as a painless mass.
- It arises from sequestered embryonic ectoderm and mesoderm, containing skin appendages, but it does not move with **deglutition** or **tongue protrusion**.
Neck Masses: Differential Diagnosis Indian Medical PG Question 3: A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
- A. 48%
- B. 12%
- C. 24%
- D. 3% (Correct Answer)
Neck Masses: Differential Diagnosis Explanation: ***3%***
- **Purely cystic thyroid nodules** (as described in this case with "isolated cystic swelling") have a **very low risk of malignancy**, typically **2-3%** or less.
- According to **ATA guidelines** and **TIRADS classification**, purely cystic nodules are considered **low suspicion** lesions.
- The cystic nature suggests a **benign process** such as a degenerated adenoma, colloid cyst, or simple cyst.
- **Fine needle aspiration (FNA)** may still be considered if the nodule is >2 cm or has any suspicious solid components, but is often not required for purely cystic lesions.
*48%*
- This percentage is **significantly higher** than the actual malignancy risk for a purely cystic thyroid swelling.
- Such a **high risk** would typically be associated with **solid nodules** exhibiting highly suspicious ultrasound features such as:
- Microcalcifications
- Irregular or spiculated margins
- Taller-than-wide shape
- Marked hypoechogenicity
- Extrathyroidal extension
*24%*
- This percentage represents a **moderate to high risk** of malignancy, which is **not characteristic** of an isolated purely cystic thyroid swelling.
- A risk in this range might be seen with:
- **Mixed solid-cystic nodules** with predominantly solid components
- Solid nodules with **intermediate suspicious features** on ultrasound
*12%*
- While lower than 24% or 48%, 12% is still **considerably higher** than the generally accepted malignancy risk for purely cystic thyroid nodules.
- This risk level could be plausible for:
- **Predominantly cystic nodules** with some eccentric solid components
- Solid nodules with **mildly suspicious** features on ultrasound
Neck Masses: Differential Diagnosis Indian Medical PG Question 4: Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
- A. Anaplastic carcinoma of thyroid
- B. Medullary carcinoma of thyroid
- C. Follicular carcinoma of thyroid (Correct Answer)
- D. Papillary carcinoma of thyroid
Neck Masses: Differential Diagnosis Explanation: ***Follicular carcinoma of thyroid***
- The definitive diagnosis of **follicular carcinoma** requires the presence of **capsular or vascular invasion**, which cannot be assessed through **fine needle aspiration cytology (FNAC)** alone [1], [5].
- FNA may show features suggestive of follicular neoplasm (e.g., hypercellularity with microfollicles), but differentiation from **follicular adenoma** requires histological examination of the excised specimen [1], [4].
*Anaplastic carcinoma of thyroid*
- **Anaplastic carcinoma** is highly aggressive and characterized by **pleomorphic, bizarre cells** that are easily identifiable on FNAC [2], [5].
- The distinctive cytological features, including **spindle cells, giant cells, and rapid cellular atypia**, allow for a relatively straightforward diagnosis via FNAC [2].
*Medullary carcinoma of thyroid*
- **Medullary carcinoma** cells have characteristic cytological features, such as **plasmacytoid appearance**, **amyloid deposition**, and **neuroendocrine granules**, which can be identified on FNAC [5].
- Confirmation can be made by **immunohistochemical staining for calcitonin** on the FNA sample [5].
*Papillary carcinoma of thyroid*
- **Papillary carcinoma** has distinct cytological features, including **orphan Annie eye nuclei**, **intranuclear grooves**, **pseudoinclusions**, and **papillary structures**, readily identified by FNAC [3].
- These features are highly specific and often allow for a definitive diagnosis of papillary thyroid carcinoma [3].
**References:**
[1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101.
[2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1101-1102.
[3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430.
[4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 428-429.
[5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 430-431.
Neck Masses: Differential Diagnosis Indian Medical PG Question 5: Lymph node metastasis in neck is almost never seen with:
- A. Carcinoma vocal cords (Correct Answer)
- B. Supraglottic carcinoma
- C. Carcinoma of tonsil
- D. Papillary carcinoma thyroid
Neck Masses: Differential Diagnosis Explanation: ***Carcinoma vocal cords***
- The **vocal cords** are relatively poor in lymphatic drainage, which significantly reduces the likelihood of regional lymph node metastasis.
- Due to this sparse lymphatic network, spread to cervical lymph nodes is rare, especially in early-stage disease.
*Supraglottic carcinoma*
- **Supraglottic** regions have a rich lymphatic network, leading to a high incidence of cervical lymph node metastasis, even in early stages.
- Bilateral lymphatic drainage further increases the risk of nodal involvement.
*Carcinoma of tonsil*
- The **tonsils** are richly supplied with lymphatic vessels, making them prone to early and frequent metastasis to cervical lymph nodes.
- Metastasis is often seen in levels II, III, and IV of the neck.
*Papillary carcinoma thyroid*
- **Papillary thyroid carcinoma** commonly metastasizes to regional lymph nodes, with documented rates as high as 30-80%.
- Nodal metastasis can occur in the central compartment (level VI) and lateral neck (levels II-V).
Neck Masses: Differential Diagnosis Indian Medical PG Question 6: 38 year old male underwent a tooth extraction at a local dental camp. After few days he develops fever and trismus. On local examination, there is a swelling at the angle of jaw . He has a poor oral hygiene and tonsils were pushed medially .No membranous covering or discharging sinus were seen around tonsils. Most likely diagnosis in this condition would be ?
- A. Ludwig's angina
- B. Parapharyngeal abscess (Correct Answer)
- C. Retropharyngeal abscess
- D. Peritonsillar abscess
Neck Masses: Differential Diagnosis Explanation: ***Parapharyngeal abscess***
- The patient's history of a recent **tooth extraction** and poor oral hygiene, followed by fever, trismus, swelling at the angle of the jaw, and medially pushed tonsils, are classic symptoms of a **parapharyngeal abscess**.
- This type of abscess develops in the **deep neck spaces** and can be caused by odontogenic infections, leading to significant swelling and potential airway compromise.
*Ludwig's angina*
- While also an odontogenic infection, **Ludwig's angina** primarily affects the **submandibular, sublingual, and submental spaces**, characterized by firm, brawny induration of the floor of the mouth and neck, with less prominent swelling at the angle of the jaw and often **tongue elevation**.
- It does not typically present with the tonsils being pushed medially, as it involves spaces anterior to the tonsillar region.
*Retropharyngeal abscess*
- A **retropharyngeal abscess** typically presents with severe **dysphagia**, odynophagia, fever, and neck stiffness, often resulting from upper respiratory tract infections or trauma.
- The swelling would be more prominent in the posterior pharyngeal wall, and would less commonly cause significant swelling at the angle of the jaw or trismus unless extensive.
*Peritonsillar abscess*
- A **peritonsillar abscess** usually develops due to a complication of tonsillitis, presenting with severe **sore throat**, unilateral tonsillar swelling, and a characteristic deviation of the **uvula** to the opposite side.
- While tonsils are affected, they are not typically pushed *medially* from an external deep neck space infection in this manner, and swelling at the angle of the jaw is less pronounced.
Neck Masses: Differential Diagnosis Indian Medical PG Question 7: Which of the following statements about Ludwig's angina is true?
- A. It is usually unilateral.
- B. It spreads by lymphatics.
- C. It is primarily a viral infection.
- D. It involves both submandibular and sublingual spaces. (Correct Answer)
Neck Masses: Differential Diagnosis Explanation: ***It involves both submandibular and sublingual spaces.***
- Ludwig's angina is a rapidly spreading, **bilateral cellulitis** involving the **submandibular, sublingual, and submental spaces**.
- Its involvement of these spaces can lead to a characteristic **"brawny" induration** of the neck and elevation of the tongue.
- This is the defining anatomical characteristic of Ludwig's angina.
*It is primarily a viral infection.*
- Ludwig's angina is a **bacterial infection**, not viral.
- The most common causative organisms are **oral flora**, including Streptococcus, Staphylococcus, and anaerobes.
- **Dental infections** (particularly from the second and third mandibular molars) are the most common source (80-90% of cases).
*It is usually unilateral.*
- Ludwig's angina is characteristically a **bilateral infection** of the floor of the mouth and neck spaces.
- Unilateral involvement would suggest a more localized infection, such as an **abscess**, rather than the diffuse cellulitis of Ludwig's angina.
*It spreads by lymphatics.*
- Ludwig's angina is a **diffuse cellulitis** that spreads via continuity through **fascial planes** and connective tissues, rather than primarily through the lymphatic system.
- The absence of significant **lymphadenopathy** is a key differentiating feature from other neck infections.
Neck Masses: Differential Diagnosis Indian Medical PG Question 8: Mark the false statement regarding Hürthle cell carcinoma:
- A. It can be diagnosed by FNAC. (Correct Answer)
- B. Arises from Hürthle cells of the thyroid.
- C. Central neck dissection is performed in certain cases.
- D. It is not a variant of papillary thyroid cancer.
Neck Masses: Differential Diagnosis Explanation: ***It can be diagnosed by FNAC.***
- **Fine-needle aspiration cytology (FNAC)** alone cannot definitively diagnose Hürthle cell carcinoma because distinguishing between **benign Hürthle cell adenoma** and **malignant Hürthle cell carcinoma** requires evidence of **capsular or vascular invasion**, which cannot be assessed cytologically [1].
- FNAC results typically return as "**follicular neoplasm, Hürthle cell type**" or "**suspicious for Hürthle cell neoplasm**," necessitating surgical excision for definitive diagnosis [1].
*Arises from Hürthle cells of the thyroid.*
- This statement is **true** because Hürthle cell carcinoma originates from **Hürthle cells** (also known as oxyphil cells or oncocytes), which are found in the thyroid gland.
- These cells are characterized by abundant **eosinophilic, granular cytoplasm** due to a high concentration of mitochondria.
*Central neck dissection is performed in certain cases.*
- This statement is **true** because **central neck dissection** is considered in Hürthle cell carcinoma when there is evidence of **lymph node metastasis** or **high-risk disease features**.
- While Hürthle cell carcinoma is less likely to metastasize to lymph nodes than papillary thyroid carcinoma, such an intervention may be necessary for staging and disease control.
*It is not a variant of papillary thyroid cancer.*
- This statement is **true** because Hürthle cell carcinoma is a distinct entity, classified as a variant of **follicular thyroid carcinoma**, not papillary thyroid carcinoma [1].
- It has a separate biological behavior and treatment strategy compared to papillary thyroid cancer.
**References:**
[1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101.
Neck Masses: Differential Diagnosis Indian Medical PG Question 9: Common differential diagnosis of verrucous carcinoma is -
- A. Adenocarcinoma
- B. Tuberculosis
- C. Condylomata lata
- D. Condylomata acuminata (Correct Answer)
Neck Masses: Differential Diagnosis Explanation: ***Condylomata acuminata***
- **Verrucous carcinoma** is a rare, well-differentiated squamous cell carcinoma that often presents as a large, exophytic, warty mass, making it clinically similar to **condylomata acuminata (genital warts)** [1].
- Both conditions can appear as **cauliflower-like lesions** on mucosal surfaces, especially in the anogenital region, necessitating **biopsy** for definitive differentiation [1].
*Adenocarcinoma*
- **Adenocarcinoma** typically arises from glandular tissue and presents as a mass or ulcer, but rarely as a **verrucous (warty)** lesion [2].
- Its histological features, characterized by **glandular differentiation**, are distinct from the acanthotic, hyperkeratotic pattern of verrucous carcinoma [2].
*Tuberculosis*
- **Tuberculosis** can cause granulomatous lesions, but these are typically **ulcerative** or **nodular**, rather than large, exophytic, warty growths characteristic of verrucous carcinoma.
- Diagnosis involves identifying **acid-fast bacilli** and characteristic granulomas with caseous necrosis, which are absent in verrucous carcinoma.
*Condylomata lata*
- **Condylomata lata** are broad, flat, moist papules associated with **secondary syphilis**, which are distinct from the exophytic, warty appearance of verrucous carcinoma [3].
- These lesions are typically **non-pruritic** and reveal spirochetes on dark-field microscopy, unlike verrucous carcinoma [3].
**References:**
[1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 974-975.
[2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 973-974.
[3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1000-1002.
Neck Masses: Differential Diagnosis Indian Medical PG Question 10: Regarding choledochal cysts following features are true except:
- A. Older presentations have an acquired variant (Correct Answer)
- B. Increased risk of cholangiocarcinoma in older presentations
- C. Congenital cysts
- D. 60% are diagnosed before 10 years
Neck Masses: Differential Diagnosis Explanation: **_Older presentations have an acquired variant_**
- Choledochal cysts are universally considered **congenital anomalies** due to an anomalous pancreaticobiliary junction, even if presenting later in life. They are not typically classified into acquired and congenital variants.
- While some theories suggest a role for acquired inflammation or obstruction in their development or progression, the underlying predisposition is congenital.
*Increased risk of cholangiocarcinoma in older presentations*
- The risk of **cholangiocarcinoma** is significantly elevated in patients with choledochal cysts, and this risk increases with age.
- Prophylactic excision is recommended due to this malignant potential, particularly in older individuals.
*Congenital cysts*
- Choledochal cysts are indeed **congenital malformations** of the bile ducts, characterized by cystic dilation of any part of the biliary tree.
- The fundamental defect is believed to be an **anomalous pancreaticobiliary junction (APBJ)**, leading to reflux of pancreatic enzymes into the bile duct.
*60% are diagnosed before 10 years*
- A significant proportion of choledochal cysts are diagnosed in **childhood**, with approximately 60% of cases identified before the age of 10 years.
- However, around 20% of cases are diagnosed in adulthood, often presenting with complications.
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