Hypopharyngeal Cancer — MCQs

10 questions

Trotter's triad is seen with:

A 50-year-old male with a long smoking history presents with a 2-month history of hoarseness, ear pain, and hemoptysis. Laryngoscopy reveals a mass on the vocal cords, and a chest X-ray shows a suspicious nodule. What is the most likely diagnosis?

Treatment of choice for carcinoma larynx T1N0M0 stage -

Second primary tumor of head and neck is most commonly seen in malignancy of:

All are risk factors of esophageal squamous cell carcinoma except:

Which cancers can cause referred otalgia (referred pain in the ear)? Select the most comprehensive answer.

A patient presented with a 3.5-cm size lymph node enlargement, which was hard and present in the submandibular region. Examination of the head and neck did not yield any lesion. Which of the following investigations should follow?

Progressive loss of hearing, tinnitus and ataxia are commonly seen in a case of -

A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?

Q10

A 16-year-old patient complains of difficulty in swallowing, difficulty in talking and sometimes difficulty in breathing. On physical examination the presentation is similar to that shown in the picture. What would be the probable diagnosis?

Hypopharyngeal Cancer Indian Medical PG Practice Questions and MCQs

Question 1: Trotter's triad is seen with:

A. Nasopharyngeal angiofibroma
B. Nasopharyngeal carcinoma (Correct Answer)
C. Cancer tongue
D. Adenoid cystic carcinoma of parotid gland

Explanation: ***Nasopharyngeal carcinoma*** - **Trotter's triad** is a classic presentation of nasopharyngeal carcinoma, particularly when the tumor involves the pharyngeal recess (fossa of Rosenmüller) and extends to involve surrounding structures. - The triad consists of: 1. **Unilateral conductive deafness** (due to Eustachian tube obstruction by the tumor) 2. **Ipsilateral trigeminal neuralgia** (usually V2 or V3 distribution, from mandibular nerve involvement) 3. **Ipsilateral palatal immobility** (due to involvement of the levator veli palatini muscle or its nerve supply) - This triad indicates advanced disease with invasion of adjacent structures. *Nasopharyngeal angiofibroma* - This is a **benign, highly vascular, locally aggressive tumor** typically found in adolescent males. - While it can cause nasal obstruction, epistaxis, and cranial nerve palsies due to extension, it does not specifically present with Trotter's triad. - The tumor arises from the sphenopalatine foramen region and extends differently than nasopharyngeal carcinoma. *Cancer tongue* - **Tongue cancer** typically presents with a **non-healing ulcer**, pain, dysphagia, and cervical lymphadenopathy. - It primarily affects the oral cavity and involves neck lymphatic drainage. - It does not involve the nasopharynx or Eustachian tube, so Trotter's triad would not occur. *Adenoid cystic carcinoma of parotid gland* - This is a malignant tumor of the salivary glands with characteristic **perineural invasion**, which can lead to pain and facial nerve palsy. - While it can involve cranial nerves (particularly CN VII), it does not affect the nasopharynx, Eustachian tube, or palatal muscles in the manner that produces Trotter's triad.

Question 2: A 50-year-old male with a long smoking history presents with a 2-month history of hoarseness, ear pain, and hemoptysis. Laryngoscopy reveals a mass on the vocal cords, and a chest X-ray shows a suspicious nodule. What is the most likely diagnosis?

A. Tuberculosis
B. Laryngeal carcinoma (Correct Answer)
C. Pneumonia
D. Chronic bronchitis

Explanation: ***Laryngeal carcinoma*** - The combination of **hoarseness, ear pain, and hemoptysis** in a patient with a **long smoking history** is highly suggestive of **laryngeal carcinoma**. - **Hoarseness** is the cardinal symptom of glottic laryngeal cancer, while **ear pain** (referred otalgia via Arnold's nerve) suggests advanced disease. - **Laryngoscopy identifying a vocal cord mass** provides direct visualization of the tumor. - The **suspicious nodule on chest X-ray** may represent a **synchronous primary lung cancer** (both share smoking as a major risk factor), **distant metastasis**, or requires further evaluation. Smokers are at high risk for multiple aerodigestive tract malignancies. *Tuberculosis* - While **hemoptysis** and a **suspicious nodule on chest X-ray** can be seen in tuberculosis, **hoarseness** and **ear pain** are not typical primary symptoms. - Laryngeal tuberculosis is rare and usually secondary to pulmonary TB with **constitutional symptoms** like fever, night sweats, and weight loss, which are not mentioned. - A **vocal cord mass** would be unusual for TB without systemic features. *Pneumonia* - **Pneumonia** typically presents with acute symptoms such as **cough, fever, dyspnea, and chills**. - **Hoarseness** and **ear pain** are not characteristic features of uncomplicated pneumonia. - A **mass on the vocal cords** is not associated with pneumonia, and the **2-month duration** is too prolonged for typical bacterial pneumonia. *Chronic bronchitis* - **Chronic bronchitis** is defined by a **chronic productive cough** for at least three months a year for two consecutive years. - While common in smokers, it typically does not cause **ear pain, hemoptysis**, or a **vocal cord mass**. - Chronic bronchitis does not produce discrete masses on laryngoscopy, differentiating it from a malignant process.

Question 3: 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 4: Second primary tumor of head and neck is most commonly seen in malignancy of:

A. Paranasal sinuses
B. Hypopharynx
C. Larynx
D. Oral cavity (Correct Answer)

Explanation: ***Oral cavity*** - Patients with **oral cavity squamous cell carcinoma** (OCSCC) have the highest incidence of developing **second primary tumors** (SPTs) in the head and neck region, often due to shared risk factors like tobacco and alcohol use. - The concept of "**field cancerization**" explains this phenomenon, where prolonged exposure to carcinogens leads to widespread genetic alterations in the mucosal lining, predisposing multiple sites to develop independent primary cancers. *Paranasal sinuses* - While paranasal sinus cancers can be aggressive, they are less commonly associated with the development of **second primary tumors** within the head and neck compared to oral cavity cancers. - The etiology of paranasal sinus cancers is often linked to specific exposures like wood dust or nickel, which are less broadly distributed across the upper aerodigestive tract compared to tobacco and alcohol. *Hypopharynx* - Hypopharyngeal cancers do carry a significant risk of developing **second primary tumors**, particularly in the esophagus and lungs, but the overall incidence of head and neck SPTs is generally considered lower than that for oral cavity cancers. - The anatomical location and typical lymphatic drainage patterns of hypopharyngeal cancers might direct SPTs to different sites compared to oral cavity cancers. *Larynx* - Laryngeal cancers, especially those of the **glottis**, are also strongly associated with tobacco and alcohol. However, the incidence of **second primary tumors** in other head and neck sites is typically reported to be lower than in oral cavity cancer patients. - While laryngeal cancer patients are at risk for SPTs in the lung and esophagus, the synchronous or metachronous development of another primary tumor *within* the head and neck region is more prevalent in oral cavity cases.

Question 5: All are risk factors of esophageal squamous cell carcinoma except:

A. Smoking
B. Achalasia cardia
C. GERD (Correct Answer)
D. Alcohol

Explanation: ***GERD*** - **Gastroesophageal reflux disease (GERD)** is strongly associated with **esophageal adenocarcinoma**, not esophageal squamous cell carcinoma. - Chronic acid reflux can lead to **Barrett's esophagus**, which is a precursor to adenocarcinoma [1]. *Smoking* - **Smoking** is a significant and well-documented risk factor for **esophageal squamous cell carcinoma**, increasing the risk in a dose-dependent manner. - Carcinogens in tobacco smoke directly damage esophageal epithelial cells, promoting malignant transformation. *Achalasia cardia* - **Achalasia cardia** involves impaired relaxation of the lower esophageal sphincter and loss of peristalsis, leading to food stasis and chronic inflammation [2]. - This chronic irritation and inflammation significantly increase the risk of developing **esophageal squamous cell carcinoma**. *Alcohol* - **Alcohol consumption**, especially heavy drinking, is a major risk factor for **esophageal squamous cell carcinoma**. - Alcohol metabolizes into acetaldehyde, a known carcinogen, which directly damages DNA in esophageal cells.

Question 6: 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 7: A patient presented with a 3.5-cm size lymph node enlargement, which was hard and present in the submandibular region. Examination of the head and neck did not yield any lesion. Which of the following investigations should follow?

A. Chest X-ray
B. Laryngoscopy
C. Supravital oral mucosa staining
D. Triple endoscopy (Correct Answer)

Explanation: ***Triple endoscopy*** - A **3.5 cm, hard, submandibular lymph node** without an obvious primary lesion suggests metastatic carcinoma, requiring a thorough search for the primary. - **Triple endoscopy** (laryngoscopy, esophagoscopy, and bronchoscopy) allows direct visualization and biopsy of mucosal surfaces in the upper aerodigestive tract, which is a common site for primary tumors metastasizing to the neck. *Chest X-ray* - While a Chest X-ray can detect **lung lesions** or mediastinal lymphadenopathy, it may not adequately identify a primary tumor in the upper aerodigestive tract. - It would be a useful adjunct later but does not provide the comprehensive mucosal surface evaluation needed to find a hidden primary. *Laryngoscopy* - **Laryngoscopy** is part of the triple endoscopy procedure but by itself is insufficient as it only examines the larynx and hypopharynx. - It would miss potential primary lesions in the nasopharynx, oral cavity, or esophagus. *Supravital oral mucosa staining* - **Supravital staining** (e.g., toluidine blue) is used to identify dysplastic or early malignant lesions on the oral mucosa. - While useful for oral cavity screening, it does not evaluate other potential primary sites in the pharynx, larynx, esophagus, or nasopharynx, which could be the source of the metastatic node.

Question 8: Progressive loss of hearing, tinnitus and ataxia are commonly seen in a case of -

A. Acoustic neuroma (Correct Answer)
B. Otitis media
C. Ependymoma
D. Cerebral glioma

Explanation: ***Acoustic neuroma*** - This benign tumor arises from the **vestibulocochlear nerve (cranial nerve VIII)**, leading to **progressive unilateral hearing loss**, **tinnitus**, and **ataxia** as it compresses the adjacent cerebellum [1]. - The symptoms are progressive and often insidious, reflecting the slow growth of the tumor, and are highly characteristic for this condition [1]. *Otitis media* - **Otitis media** is an **inflammation/infection of the middle ear**, primarily causing ear pain, ear discharge, and conductive hearing loss. - While it causes hearing loss, it typically presents with acute symptoms and does not typically cause **tinnitus** or **ataxia** unless there are severe complications affecting the inner ear or brain. *Ependymoma* - **Ependymomas** are tumors originating from the **ependymal cells** lining the ventricles and spinal cord, often causing symptoms related to increased intracranial pressure (headache, nausea) or spinal cord compression. - They do not typically present with the specific triad of **progressive hearing loss**, **tinnitus**, and **ataxia** characteristic of acoustic neuroma. *Cerebral glioma* - **Cerebral gliomas** are brain tumors that arise from glial cells and present with a wide range of neurological symptoms depending on their location, such as **seizures**, **weakness**, or **cognitive changes**. - They are unlikely to present with the specific combination of **progressive hearing loss**, **tinnitus**, and **ataxia** unless located in the brainstem or cerebellum in a way that specifically compresses the eighth cranial nerve and cerebellar pathways, which is less common than for an acoustic neuroma.

Question 9: A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?

A. Direct laryngoscopy with biopsy (Correct Answer)
B. MRI of neck
C. CT scan of neck
D. Radiotherapy

Explanation: ***Direct laryngoscopy with biopsy*** - A definitive diagnosis of a vocal cord mass requires **histological examination** to rule out malignancy, especially given the patient's risk factors (age, smoking) and symptoms (hoarseness, dysphagia, weight loss). - **Direct laryngoscopy** allows for a thorough, magnified view of the mass and precise biopsy collection, which is superior to flexible laryngoscopy alone for definitive diagnosis and staging. *MRI of neck* - While MRI can provide excellent soft tissue detail for **staging** a known malignancy, it cannot provide a **histological diagnosis**. - It would typically be performed after a biopsy confirms malignancy to assess the extent of the tumor and potential spread. *CT scan of neck* - A CT scan is useful for evaluating **bony involvement**, lymph node status, and tumor extension for **staging purposes**, but it is not a diagnostic tool for identifying the specific type of tissue or cell pathology. - Like MRI, a CT scan would generally follow a biopsy confirming malignancy. *Radiotherapy* - **Radiotherapy** is a treatment modality for laryngeal cancer, not a diagnostic step. - Initiating treatment without a definitive histological diagnosis of malignancy would be inappropriate and potentially harmful.

Question 10: A 16-year-old patient complains of difficulty in swallowing, difficulty in talking and sometimes difficulty in breathing. On physical examination the presentation is similar to that shown in the picture. What would be the probable diagnosis?

A. Ranula
B. Lingual thyroid (Correct Answer)
C. Enlarged adenoids
D. Vallecular cyst

Explanation: ***Lingual thyroid*** - The image shows a **mass at the base of the tongue**, which is typical of a lingual thyroid, an ectopic thyroid tissue. - Symptoms like **difficulty swallowing (dysphagia)**, **difficulty talking (dysphonia)**, and **difficulty breathing (dyspnea)** are common with a lingual thyroid due to its obstructive nature. - Lingual thyroid results from **failure of thyroid descent** during embryological development and is the most common ectopic thyroid location. *Ranula* - A ranula is a **mucus extravasation cyst** found on the **floor of the mouth**, usually unilateral and bluish. - While it can cause speech or swallowing difficulties, its location is distinct from the mass seen at the tongue base. *Vallecular cyst* - A vallecular cyst is a **mucus retention cyst** located in the **vallecula** (between the base of tongue and epiglottis). - Can present with dysphagia and respiratory symptoms, but typically appears more **cystic and translucent** rather than solid tissue mass. - Less common in adolescents compared to lingual thyroid. *Enlarged adenoids* - Enlarged adenoids are located in the **nasopharynx** and typically cause nasal obstruction, mouth breathing, and recurrent ear infections. - They would not present as a visible mass at the base of the tongue nor cause dysphagia or dysphonia to this extent.

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