Nasopharyngeal Carcinoma — MCQs
A 60-year-old male presents with painless cervical lymphadenopathy. On examination, the right ear reveals conductive hearing loss with a dull tympanic membrane. Moreover, decreased mobility of the soft palate was also noted. What is the probable diagnosis?
Treatment of choice for carcinoma larynx T1N0M0 stage -
Trotter's syndrome involves:
Which of the following is associated with nasopharyngeal cancer?
A person presents with neck node and B type tympanogram. What is the most likely diagnosis?
Which of the following is NOT a component of Trotter's triad associated with nasopharyngeal carcinoma?
Type of speech seen in nasopharyngeal carcinoma -
A 25-year-old patient came to medicine OPD with complaints of sore throat and a slightly itchy rash. On examination, pharyngeal erythema with bilateral tender cervical lymphadenopathy is noted. Throat swab is sent for microbiological examination. Peripheral blood film revealed the following finding. Which of the following malignant conditions are not associated with the above infection?
What is the most common cause of deafness in a patient with Nasopharyngeal Carcinoma:
Treatment of choice for locoregionally advanced nasopharyngeal carcinoma is:
Nasopharyngeal Carcinoma Indian Medical PG Practice Questions and MCQs
Question 1: A 60-year-old male presents with painless cervical lymphadenopathy. On examination, the right ear reveals conductive hearing loss with a dull tympanic membrane. Moreover, decreased mobility of the soft palate was also noted. What is the probable diagnosis?
- A. Adenoid cystic cancer
- B. Nasopharyngeal carcinoma (Correct Answer)
- C. Juvenile nasopharyngeal angiofibroma
- D. Quinsy
Explanation: ***Nasopharyngeal carcinoma*** - This presentation with **painless cervical lymphadenopathy**, **conductive hearing loss** due to Eustachian tube obstruction, and **cranial nerve involvement** (affecting the soft palate mobility) is highly suggestive of nasopharyngeal carcinoma, which often metastasizes early. - The conductive hearing loss, specifically a **dull tympanic membrane**, points to **otitis media with effusion** secondary to Eustachian tube dysfunction, a common presentation of nasopharyngeal masses obstructing the tube. *Adenoid cystic cancer* - While adenoid cystic carcinoma can cause cranial nerve palsies due to **perineural invasion**, it more commonly arises in the salivary glands and not typically presents with nasopharyngeal masses causing Eustachian tube obstruction. - It usually presents with a **palpable mass** or **pain**, which is not the primary presentation here. *Juvenile nasopharyngeal angiofibroma* - This is a **benign vascular tumor** typically presenting in **adolescent males** with episodes of **severe epistaxis** and **nasal obstruction**. - It does not commonly present with cervical lymphadenopathy or cranial nerve involvement and is rare in a 60-year-old. *Quinsy* - Quinsy, or **peritonsillar abscess**, presents acutely with **severe sore throat**, **fever**, **trismus**, and sometimes **uvular deviation**. - It is an **infectious condition** and does not typically cause painless cervical lymphadenopathy or conductive hearing loss as described.
Question 2: Treatment of choice for carcinoma larynx T1N0M0 stage -
- A. External beam radiotherapy (Correct Answer)
- B. Surgery
- C. Radioactive implants
- D. Surgery & radiotherapy
Explanation: ***External beam radiotherapy*** - For **early-stage laryngeal cancer (T1N0M0)**, both **radiotherapy and surgery are considered equally effective first-line treatments** with excellent local control rates (>90%). - EBRT offers the advantage of being **completely non-invasive** while preserving vocal function and avoiding surgical risks. - Treatment duration is typically **6-7 weeks**, requiring patient compliance with daily fractions. - Preferred when patient prefers non-invasive approach or has comorbidities making surgery high-risk. *Surgery* - **Transoral laser microsurgery (TLS)** or endoscopic **cordectomy** are equally effective surgical options for T1 glottic cancer with cure rates comparable to radiotherapy. - Modern laser techniques provide excellent **voice preservation** with minimal morbidity. - Advantages include **shorter treatment time** (single procedure), obtaining tissue for histopathology, and preserving radiotherapy as salvage option. - Both **surgery and radiotherapy are Category 1 recommendations** for T1N0M0 disease; choice depends on institutional expertise, patient preference, and individual factors. *Radioactive implants* - **Brachytherapy (radioactive implants)** can be used for early-stage glottic cancer at specialized centers. - However, **external beam radiotherapy** is more commonly employed due to greater accessibility and extensive outcome data. *Surgery & radiotherapy* - **Combined modality treatment** is indicated for **locally advanced disease** (T3-T4) or **node-positive disease** (N+). - For **T1N0M0 disease**, single modality (either surgery OR radiotherapy) is sufficient and preferred to minimize treatment-related morbidity.
Question 3: Trotter's syndrome involves:
- A. Nasopharynx (Correct Answer)
- B. Oropharynx
- C. Pharynx
- D. Larynx
Explanation: ***Nasopharynx*** - **Trotter's syndrome** is a classic triad of symptoms (unilateral conductive hearing loss, trigeminal neuralgia, and soft palate paralysis) associated with malignant tumors of the **nasopharynx** [1]. - The syndrome arises from the tumor's invasion of critical structures surrounding the **nasopharynx**, including the Eustachian tube, trigeminal nerve, and cranial nerves IX, X, XI [1]. *Oropharynx* - Malignancies of the **oropharynx** typically present with symptoms such as dysphagia, odynophagia, globus sensation, and referred otalgia to the ear, rather than the specific triad of Trotter's syndrome. - While oropharyngeal tumors can metastasize, they do not directly cause the unique combination of symptoms seen in Trotter's syndrome due to their anatomical location. *Pharynx* - The **pharynx** is a broader anatomical region encompassing the nasopharynx, oropharynx, and hypopharynx. While Trotter's syndrome involves a part of the pharynx (the nasopharynx), simply stating "Pharynx" is too general and lacks the specificity required for this syndrome. - The specific symptoms of Trotter's syndrome are linked to tumor involvement in a very particular area of the pharynx, not the entire structure. *Larynx* - Tumors of the **larynx** primarily cause symptoms related to voice changes (hoarseness), stridor, and difficulty breathing or swallowing. - The anatomical position of the larynx is distinct from the nasopharynx, and therefore, laryngeal pathologies do not lead to the specific neurological and auditory symptoms characterizing Trotter's syndrome.
Question 4: Which of the following is associated with nasopharyngeal cancer?
- A. Herpes Simplex Virus 1 (HSV-1)
- B. Epstein-Barr Virus (EBV) (Correct Answer)
- C. Herpes Simplex Virus 2 (HSV-2)
- D. Varicella-Zoster Virus (VZV)
Explanation: ***Epstein-Barr Virus (EBV)*** - **Epstein-Barr Virus** is strongly and consistently associated with the development of **nasopharyngeal carcinoma (NPC)**, particularly the undifferentiated type. - EBV DNA is often detected in NPC tumor cells, and the virus plays a significant role in **tumorigenesis**. *Herpes Simplex Virus 1 (HSV-1)* - **HSV-1** is primarily associated with **oral herpes** (cold sores) and occasionally **genital herpes**, but not nasopharyngeal cancer. - While it establishes latency in neurons, there is no direct causal link between HSV-1 infection and NPC. *Herpes Simplex Virus 2 (HSV-2)* - **HSV-2** is the main cause of **genital herpes** and is transmitted sexually, but it is not associated with nasopharyngeal cancer. - It establishes latency in sacral ganglia, and its oncogenic potential is primarily linked to cervical cancer in conjunction with HPV, not NPC. *Varicella-Zoster Virus (VZV)* - **VZV** causes **chickenpox** (varicella) in children and **shingles** (herpes zoster) in adults, but it is not linked to nasopharyngeal cancer. - VZV establishes latency in sensory ganglia and reactivates to cause neurological and dermatological symptoms.
Question 5: A person presents with neck node and B type tympanogram. What is the most likely diagnosis?
- A. Acoustic neuroma
- B. Nasopharyngeal CA (Correct Answer)
- C. None of the options
- D. Angiofibroma
Explanation: ***Nasopharyngeal CA*** - A **neck node** can be a presenting symptom of **nasopharyngeal carcinoma (NPC)** due to metastatic spread to cervical lymph nodes, often as the first presenting feature in ~75% of cases. - A **Type B tympanogram** indicates reduced compliance of the tympanic membrane, often due to **otitis media with effusion (OME)**, which can be caused by Eustachian tube obstruction from a nasopharyngeal mass like NPC. - This is the **classic presentation** combining lymphadenopathy with conductive hearing loss/middle ear effusion. *Acoustic neuroma* - An **acoustic neuroma** (vestibular schwannoma) typically presents with **unilateral sensorineural hearing loss**, tinnitus, and balance issues. - It does not directly cause an obstructive process leading to a Type B tympanogram or cervical lymphadenopathy. - Metastasis from acoustic neuroma is extremely rare. *Angiofibroma* - **Angiofibroma** is a benign, highly vascular tumor typically found in the **nasopharynx**, primarily affecting adolescent males. - While it can cause **nasal obstruction** and epistaxis, leading to Eustachian tube dysfunction and a Type B tympanogram, it is **benign and does not metastasize** to neck nodes. - This is a key differentiating feature from nasopharyngeal carcinoma.
Question 6: Which of the following is NOT a component of Trotter's triad associated with nasopharyngeal carcinoma?
- A. Palatal paralysis
- B. Trigeminal Neuralgia
- C. Conduction deafness
- D. Sensorineural deafness (Correct Answer)
Explanation: ***Sensorineural deafness*** - **Trotter's triad** specifically refers to unilateral **painless conductive hearing loss**, **trigeminal neuralgia**, and **palatal paralysis** in the context of nasopharyngeal carcinoma. - Sensorineural deafness is not typically part of this classic triad as the tumor's direct pressure tends to affect the Eustachian tube leading to conductive hearing loss. *Palatal paralysis* - This is a key component of **Trotter's triad**, resulting from the tumor's invasion of the **IX (glossopharyngeal)** and **X (vagus)** cranial nerves, which innervate the soft palate. - It leads to **dysphagia** and **dysarthria**, often presenting as an early symptom. *Trigeminal Neuralgia* - This refers to **unilateral facial pain** due to involvement of the **V (trigeminal)** cranial nerve, which is a core symptom of **Trotter's triad**. - The tumor's extension can cause compression or infiltration of the nerve, leading to sharp, shooting pains. *Conduction deafness* - This is a cardinal sign of **Trotter's triad** and is caused by the nasopharyngeal tumor obstructing the **Eustachian tube**. - Obstruction leads to fluid accumulation in the middle ear, resulting in **painless unilateral conductive hearing loss**.
Question 7: 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 8: A 25-year-old patient came to medicine OPD with complaints of sore throat and a slightly itchy rash. On examination, pharyngeal erythema with bilateral tender cervical lymphadenopathy is noted. Throat swab is sent for microbiological examination. Peripheral blood film revealed the following finding. Which of the following malignant conditions are not associated with the above infection?
- A. Hodgkin disease
- B. Burkitt's lymphoma
- C. Nasopharyngeal carcinoma
- D. B cell lymphoma (immunocompetent patient) (Correct Answer)
Explanation: ***B cell lymphoma (immunocompetent patient)*** - The image shows **atypical lymphocytes**, characteristic of infectious mononucleosis, typically caused by the **Epstein-Barr Virus (EBV)**. EBV is associated with several malignancies, but primary B-cell lymphoma in an immunocompetent patient is not a direct consequence of EBV infection, unlike post-transplant lymphoproliferative disorder. - While EBV infects B cells, leading to their proliferation, a normal immune system usually controls this. The specific malignant transformation to B-cell lymphoma without underlying immunodeficiency is not a direct, well-established association with EBV infection. It's more commonly linked to specific genetic translocations or immunodeficiency. *Hodgkin disease* - **Epstein-Barr Virus (EBV)** has a strong association with a significant proportion of classic Hodgkin lymphoma cases, particularly the mixed-cellularity and lymphocyte-depleted subtypes. - EBV DNA can be found in the **Reed-Sternberg cells** characteristic of Hodgkin lymphoma. *Burkitt's lymphoma* - **Endemic Burkitt's lymphoma**, prevalent in equatorial Africa, is strongly linked to **Epstein-Barr Virus (EBV)** and chronic malaria. - EBV contributes to the pathogenesis by promoting B-cell proliferation, which can lead to the characteristic **MYC translocation**. *Nasopharyngeal carcinoma* - **Epstein-Barr Virus (EBV)** is consistently associated with all histological types of nasopharyngeal carcinoma (NPC), particularly the undifferentiated type. - EBV infection is considered a **necessary cofactor** in the development of NPC, with viral DNA found in almost all tumor cells.
Question 9: What is the most common cause of deafness in a patient with Nasopharyngeal Carcinoma:
- A. Fluid accumulation in the middle ear due to eustachian tube obstruction (Correct Answer)
- B. Middle ear Infection
- C. Metastasis to Temporal Bone
- D. Infiltration of Tumour into middle ear
Explanation: ***Fluid accumulation in the middle ear due to eustachian tube obstruction*** - **Nasopharyngeal carcinoma** often grows in close proximity to the opening of the **eustachian tube**, leading to its obstruction. - Obstruction of the eustachian tube prevents proper ventilation of the middle ear, leading to a build-up of fluid (**serous otitis media**), which causes a **conductive hearing loss**. *Middle ear Infection* - While middle ear infections can cause deafness, they are not the most common cause of hearing loss directly attributable to **nasopharyngeal carcinoma**. - **Fluid accumulation due to Eustachian tube dysfunction** precedes infection and is the primary mechanism linked to the tumor. *Metastasis to Temporal Bone* - **Metastasis to the temporal bone** can occur in advanced stages of nasopharyngeal carcinoma, causing hearing loss. - However, direct **eustachian tube obstruction and serous otitis media** are significantly more common initial presentations of hearing impairment. *Infiltration of Tumour into middle ear* - While direct tumor infiltration into the middle ear can lead to deafness, it is less common than the effect of **eustachian tube obstruction**. - **Tumor infiltration** typically indicates more advanced local disease, whereas **eustachian tube dysfunction** can be an early symptom.
Question 10: Treatment of choice for locoregionally advanced nasopharyngeal carcinoma is:
- A. Chemotherapy
- B. Radiotherapy
- C. Concurrent chemoradiotherapy (Correct Answer)
- D. Surgery
Explanation: ***Concurrent Chemoradiotherapy*** - **Concurrent chemoradiotherapy** is the current standard of care for locoregionally advanced nasopharyngeal carcinoma (Stage II-IVB), which represents the majority of NPC cases at presentation. - The combination provides superior locoregional control and overall survival compared to radiotherapy alone, as demonstrated in multiple randomized controlled trials. - **Cisplatin-based chemotherapy** given concurrently with radiotherapy is the most widely used regimen, with cisplatin typically administered on a weekly or three-weekly basis during radiation. *Radiotherapy* - **Radiotherapy alone** is the treatment of choice only for **early-stage (Stage I)** nasopharyngeal carcinoma, which represents a minority of cases. - While NPC is highly radiosensitive, radiotherapy alone has inferior outcomes compared to concurrent chemoradiotherapy in advanced stages. *Chemotherapy* - **Chemotherapy alone** is not curative and is reserved for palliation in metastatic or recurrent disease. - It does not provide adequate local control for primary nasopharyngeal carcinoma. *Surgery* - **Surgery** is not the primary treatment modality due to the tumor's anatomical location at the skull base and proximity to critical neurovascular structures. - It may be considered for salvage treatment of residual or recurrent neck nodes after chemoradiotherapy (salvage neck dissection).
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