Hypopharyngeal Carcinoma — MCQs
Which cancers can cause referred otalgia (referred pain in the ear)? Select the most comprehensive answer.
N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:
In acoustic neuroma, which cranial nerve is involved earliest?
Treatment of choice for nasopharyngeal carcinoma T1 is:
A 45-year-old patient presents with persistent hoarseness for 3 months. Which finding on indirect laryngoscopy is most concerning for malignancy?
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?
Most common presentation in nasopharyngeal carcinoma is with:
A patient presented with 2 days history of fever. On examination there was a swelling in the neck and one side tonsil was pushed to midline. What is the most likely diagnosis:-
Type of speech seen in nasopharyngeal carcinoma -
Killian's Dehiscence is seen at the level of:
Hypopharyngeal Carcinoma Indian Medical PG Practice Questions and MCQs
Question 1: Which cancers can cause referred otalgia (referred pain in the ear)? Select the most comprehensive answer.
- A. Cancer of the pharynx
- B. Cancer of the oral cavity
- C. Cancer of the pharynx, oral cavity, and larynx (Correct Answer)
- D. Cancer of the larynx
Explanation: ***Cancer of the pharynx, oral cavity, and larynx*** - Cancers in these locations can cause **referred otalgia** due to shared innervation of the ear by cranial nerves that also supply these areas. - Specifically, the **glossopharyngeal nerve (IX)**, **vagus nerve (X)**, and **trigeminal nerve (V3)** are involved in both sensation from these head and neck regions and the ear. *Cancer of the pharynx* - While pharyngeal cancer can cause **referred otalgia** through cranial nerves IX and X, it is not the most comprehensive answer as other sites are also involved. - This option exclusively mentions the pharynx, missing other important anatomical locations that can also refer pain to the ear. *Cancer of the oral cavity* - Cancer here can cause **referred otalgia**, primarily through the **trigeminal nerve (V3)**, which innervates parts of the oral cavity and the ear. - However, similar to pharyngeal cancer, this option is not comprehensive as it omits other regions related to referred ear pain. *Cancer of the larynx* - Laryngeal cancer can cause **referred otalgia** via the **vagus nerve (X)**, specifically its superior laryngeal branch. - This option is also incomplete as it does not include cancers of the pharynx or oral cavity, which are equally important causes of referred ear pain.
Question 2: N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:
- A. Metastasis in a lymph node >6 cm (Correct Answer)
- B. Metastasis in lymph nodes >2 cm
- C. Metastasis in lymph nodes >5 cm
- D. None of the options
Explanation: ***Metastasis in a lymph node >6 cm*** - **N3a disease** in head and neck cancer staging (AJCC 8th edition) specifically refers to metastasis in a single lymph node larger than 6 cm in greatest dimension **without extranodal extension (ENE)**. - This applies to oral cavity, oropharynx (HPV-negative), hypopharynx, and larynx cancers. - **Note:** N3 staging also includes **N3b** (metastasis in any node with clinically overt ENE), but this question specifically asks about N3a criteria. *Metastasis in lymph nodes >2 cm* - Lymph nodes in the 2-3 cm range typically fall within **N1 or N2a categories**, depending on laterality and number of involved nodes. - **N3a disease** requires a single lymph node to exceed 6 cm in greatest dimension without ENE. *Metastasis in lymph nodes >5 cm* - A lymph node between 3-6 cm is usually classified as **N2 disease** (N2a if single ipsilateral ≤6 cm, N2b if multiple ipsilateral ≤6 cm, N2c if bilateral or contralateral ≤6 cm). - To be classified as **N3a**, the lymph node must be **>6 cm** without extranodal extension. *None of the options* - This option is incorrect because the first option accurately describes the size criterion for **N3a TNM staging** in head and neck tumors according to AJCC 8th edition guidelines. - While N3 staging has two subcategories (N3a and N3b), the size criterion of >6 cm correctly defines N3a disease.
Question 3: In acoustic neuroma, which cranial nerve is involved earliest?
- A. CN V
- B. CN VII
- C. CN VIII (Correct Answer)
- D. CN X
Explanation: ***CN VIII*** - An **acoustic neuroma** (also known as a **vestibular schwannoma**) originates from the **Schwann cells** of the **vestibulocochlear nerve (CN VIII)**. - Due to its origin, symptoms related to **hearing loss**, **tinnitus**, and **balance issues** (all functions of CN VIII) are typically the earliest to manifest [1]. *CN V* - The **trigeminal nerve (CN V)** is responsible for **facial sensation** and **mastication**. - Compression of CN V usually occurs in later stages of acoustic neuroma growth, leading to **facial numbness** or **pain**. *CN VII* - The **facial nerve (CN VII)** controls **facial expressions** and taste sensation in the anterior two-thirds of the tongue. - **Facial weakness** or **paralysis** due to CN VII involvement typically occurs after significant tumor growth, as the nerve runs adjacent to the acoustic neuroma [1]. *CN X* - The **vagus nerve (CN X)** is involved in diverse functions including **swallowing**, **speech**, and **autonomic regulation** of organs like the heart and digestive tract. - **Vagal nerve** symptoms such as **dysphagia** or **hoarseness** are extremely rare in acoustic neuromas and would indicate a very extensive tumor likely compressing structures much more distant from the primary site.
Question 4: Treatment of choice for nasopharyngeal carcinoma T1 is:
- A. Radiation therapy (Correct Answer)
- B. Chemotherapy
- C. Observation
- D. Surgery
Explanation: ***Radiation therapy*** - **Radiation therapy** (RT) is the primary treatment modality for early-stage (T1) nasopharyngeal carcinoma due to the tumor's high radiosensitivity and its anatomical location, which makes surgical resection challenging. - The goal is to deliver a definitive dose of radiation to the tumor with curative intent, often using techniques like intensity-modulated radiation therapy (IMRT) to spare surrounding critical structures. - T1 NPC has excellent cure rates (>90%) with RT alone. *Chemotherapy* - **Chemotherapy** is generally used in combination with radiation for locally advanced nasopharyngeal carcinoma (stage II-IVB) or for metastatic disease, not typically as monotherapy for T1 tumors. - While concurrent chemoradiotherapy improves outcomes in more advanced stages, it's not the primary curative treatment for early-stage disease and adds unnecessary toxicity. *Observation* - **Observation** or watchful waiting is not appropriate for nasopharyngeal carcinoma, even at T1 stage, as NPC is an aggressive malignancy requiring active treatment. - Unlike some indolent tumors, NPC has potential for local progression and early lymphatic spread, necessitating definitive treatment at diagnosis. *Surgery* - **Surgery** plays a very limited role in the primary treatment of nasopharyngeal carcinoma, especially for T1 lesions. - The nasopharynx's deep anatomical location, proximity to skull base, critical neurovascular structures, and the tumor's infiltrative nature make surgical resection technically challenging with high morbidity. - Surgery might be considered for salvage in selected cases of recurrent disease after radiation failure, but it is not the first-line treatment.
Question 5: A 45-year-old patient presents with persistent hoarseness for 3 months. Which finding on indirect laryngoscopy is most concerning for malignancy?
- A. Reinke's edema
- B. Unilateral cord paralysis (Correct Answer)
- C. Bilateral polyps
- D. Vocal cord nodules
Explanation: ***Unilateral cord paralysis*** - **Unilateral cord paralysis** can be an indicator of an underlying malignancy impinging on the **recurrent laryngeal nerve**, which innervates the vocal cords. - The **persistent hoarseness** for 3 months, combined with paralysis, raises significant concern for a malignant process in the head, neck, or chest. *Reinke's edema* - **Reinke's edema** is typically associated with **chronic irritation** like smoking and presents as a swollen, gelatinous fluid collection in the superficial lamina propria. - While it causes hoarseness, it is a **benign condition** and not directly indicative of malignancy. *Bilateral polyps* - **Vocal cord polyps** are typically **benign lesions** often caused by vocal trauma or abuse, and while they can cause hoarseness, they are not usually a direct sign of malignancy, especially when bilateral. - While requiring management, polyps themselves do **not raise immediate concern for cancer** compared to paralysis. *Vocal cord nodules* - **Vocal cord nodules** (singer's nodules) are benign, bilateral lesions caused by **vocal abuse** and are a common cause of hoarseness. - They are a benign condition and do not suggest an underlying malignancy at their core.
Question 6: 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)
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
Question 7: Most common presentation in nasopharyngeal carcinoma is with:
- A. Cervical lymphadenopathy (Correct Answer)
- B. Epistaxis
- C. Hoarseness of voice
- D. Nasal stuffiness
Explanation: ***Cervical lymphadenopathy*** - **Cervical lymphadenopathy** is the most frequent initial symptom, with over 75% of patients presenting with a palpable neck mass, often a **painless, firm mass** in the upper deep cervical chain. - This is due to the rich lymphatic drainage of the nasopharynx to the cervical lymph nodes, leading to early metastasis. *Epistaxis* - While **epistaxis** (nosebleeds) can occur in nasopharyngeal carcinoma, it is generally not the most common presenting symptom. - It usually presents as recurrent, mild **epistaxis** or bloody discharge rather than severe bleeding. *Hoarseness of voice* - **Hoarseness of voice** is typically associated with laryngeal involvement or recurrent laryngeal nerve palsy, which is a less common and usually later manifestation of nasopharyngeal carcinoma. - Primary nasopharyngeal tumors do not directly cause hoarseness unless they extend significantly or metastasize to structures affecting vocal cord function. *Nasal stuffiness* - **Nasal stuffiness** or obstruction can be a symptom due to tumor growth within the nasopharynx. - However, it is a less specific symptom and often overshadowed by the more prominent presentation of cervical lymphadenopathy.
Question 8: A patient presented with 2 days history of fever. On examination there was a swelling in the neck and one side tonsil was pushed to midline. What is the most likely diagnosis:-
- A. Retropharyngeal abscess
- B. Parapharyngeal abscess
- C. Tonsillitis
- D. Quinsy (Correct Answer)
Explanation: ***Quinsy (Peritonsillar abscess)*** - **Quinsy** is a **peritonsillar abscess** that presents with fever, severe throat pain, and the pathognomonic sign of **unilateral tonsil pushed toward the midline**. - The abscess forms in the **peritonsillar space** (between the tonsillar capsule and superior constrictor muscle), causing **medial displacement of the tonsil** and **bulging of the soft palate**. - Patients typically have **trismus, dysphagia, "hot potato voice"** and may have visible neck swelling. - This clinical presentation exactly matches the description: tonsil pushed to midline is the **classic finding for peritonsillar abscess**. *Parapharyngeal abscess* - A **parapharyngeal abscess** involves the deep parapharyngeal space lateral to the pharynx. - While it can cause neck swelling and fever, it typically causes **fullness and induration of the lateral pharyngeal wall** rather than prominent medial displacement of the tonsil itself. - The **tonsil is usually NOT pushed to the midline** in parapharyngeal abscess; instead, there is lateral pharyngeal wall bulging. - Often presents with more prominent external neck swelling below the angle of mandible. *Retropharyngeal abscess* - A **retropharyngeal abscess** occurs in the retropharyngeal space behind the posterior pharyngeal wall. - Presents with **posterior pharyngeal wall bulge**, neck stiffness, and dysphagia. - Does **NOT cause medial displacement of the tonsil** as the abscess is posterior, not lateral to the tonsil. *Tonsillitis* - **Acute tonsillitis** causes bilateral tonsillar inflammation with erythema and exudates. - While both tonsils may be enlarged, there is **no unilateral medial displacement** of one tonsil. - Less likely to cause significant neck swelling compared to deep space infections.
Question 9: Type of speech seen in nasopharyngeal carcinoma -
- A. Hot potato voice
- B. Hoarse voice
- C. Rhinolalia clausa (Correct Answer)
- D. Rhinolalia aperta
Explanation: ***Rhinolalia clausa*** - This is also known as **hyponasal speech** or **closed nasality**, where there is insufficient nasal airflow during speech. - In **nasopharyngeal carcinoma**, the tumor can obstruct the nasopharynx, preventing air from flowing into the nasal cavity during vocalization, leading to this type of speech. *Hot potato voice* - This type of dysphonia is characterized by **muffled speech** as if the speaker is trying to talk with a hot object in their mouth. - It is typically associated with conditions causing **pharyngeal or tonsillar swelling** or peritonsillar abscess, which are distinct from nasopharyngeal carcinoma. *Hoarse voice* - **Hoarseness** results from abnormal vibration of the vocal cords, leading to a rough or breathy voice. - While possible in advanced nasopharyngeal carcinoma due to cranial nerve involvement affecting vocal cords, it is not the primary or most characteristic speech alteration from the tumor's location within the nasopharynx. *Rhinolalia aperta* - Also known as **hypernasal speech** or **open nasality**, this occurs when there is excessive nasal airflow during speech, making non-nasal sounds sound nasal. - This is typically caused by **velopharyngeal insufficiency** or defects that prevent proper closure between the oral and nasal cavities, such as a cleft palate, which is the opposite of the obstruction seen in nasopharyngeal carcinoma.
Question 10: Killian's Dehiscence is seen at the level of:
- A. Inferior Constrictor (Correct Answer)
- B. Superior Constrictor
- C. Middle constrictor
- D. Thyroepiglottic
Explanation: ***Inferior Constrictor*** - **Killian's dehiscence** is a triangular area of weakness in the posterior pharyngeal wall, located between the **thyropharyngeal** and **cricopharyngeal** parts of the inferior constrictor muscle. - This anatomical weakness is a common site for the formation of a **Zenker's diverticulum**. *Superior Constrictor* - The superior constrictor muscle is located higher up in the pharynx and is not associated with Killian's dehiscence. - Its weakness is related to **Passavant's ridge**, which is important for speech and swallowing, not Zenker's diverticulum. *Middle constrictor* - The middle constrictor muscle is positioned between the superior and inferior constrictors, and there is no specific dehiscence named after it associated with diverticula. - Its function primarily involves constricting the pharynx during swallowing. *Thyroepiglottic* - The thyroepiglottic is a muscle of the **larynx**, not the pharynx, and it is involved in vocal fold tension and airway protection. - It does not contribute to the structure of the pharyngeal wall or the formation of Killian's dehiscence.
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