ENT Oncology — MCQs

ENT Oncology Indian Medical PG Practice Questions and MCQs

Question 91: Which of the following is NOT a cause of oropharyngeal carcinoma?

A. Occupational exposure to hydrochloric acid (Correct Answer)
B. Smoking
C. Human Papilloma Virus infection
D. Plummer-Vinson syndrome

Explanation: **Explanation:** Oropharyngeal carcinoma primarily arises from the mucosal lining of the soft palate, base of tongue, tonsils, and posterior pharyngeal wall. Understanding its etiology is crucial for NEET-PG. **Why Option A is correct:** **Occupational exposure to hydrochloric acid (HCl)** is associated with dental erosion and irritation of the upper respiratory tract, but it is **not** a recognized risk factor for oropharyngeal carcinoma. In contrast, exposure to wood dust (nasal adenocarcinoma) or nickel/chromium (sinonasal squamous cell carcinoma) are classic occupational associations in ENT oncology. **Why the other options are incorrect:** * **Smoking (Option B):** Tobacco contains potent carcinogens (like nitrosamines) that cause field cancerization. It remains a leading cause of oropharyngeal and laryngeal cancers. * **Human Papilloma Virus (Option C):** HPV (specifically **Type 16**) is now a major driver of oropharyngeal cancer, particularly in the tonsils and base of tongue. These patients are typically younger, non-smokers, and have a better prognosis than tobacco-related cases. * **Plummer-Vinson Syndrome (Option D):** Also known as Paterson-Brown-Kelly syndrome, it is characterized by iron-deficiency anemia, glossitis, and esophageal webs. It is a well-known premalignant condition for **post-cricoid carcinoma** and oropharyngeal squamous cell carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Palatine tonsil. * **Most common histology:** Squamous Cell Carcinoma (SCC). * **HPV Status:** p16 protein expression is used as a surrogate marker for HPV-positive status in immunohistochemistry. * **Eagle’s Syndrome:** Often a differential diagnosis for oropharyngeal pain (elongated styloid process).

Question 92: Trotter's triad consists of the following, except:

A. Conduction deafness
B. Trigeminal neuralgia
C. VII nerve palsy (Correct Answer)
D. Ipsilateral soft palate immobility

Explanation: **Explanation:** **Trotter’s Triad** is a clinical diagnostic cluster associated with advanced **Nasopharyngeal Carcinoma (NPC)**, specifically when the tumor invades the lateral pharyngeal wall (Sinus of Morgagni). **Why VII Nerve Palsy is the correct answer:** The Facial nerve (VII) is not part of Trotter’s Triad. The triad involves structures in the immediate vicinity of the nasopharynx and the skull base (foramen lacerum). While NPC can cause multiple cranial nerve palsies (most commonly VI), VII nerve involvement is rare and not a defining feature of this specific triad. **Analysis of the Triad Components (Incorrect Options):** 1. **Conduction Deafness (Option A):** Caused by the tumor obstructing the **Eustachian tube** orifice. This leads to negative middle ear pressure and subsequent serous otitis media (Otitis Media with Effusion). 2. **Trigeminal Neuralgia (Option B):** Specifically involving the **Mandibular division (V3)**. As the tumor infiltrates the skull base or the parapharyngeal space, it causes referred pain to the ear or jaw and anesthesia/paresthesia along the V3 distribution. 3. **Ipsilateral Soft Palate Immobility (Option D):** Occurs due to direct infiltration of the **Levator Veli Palatini** muscle or involvement of the pharyngeal plexus. This results in the "curtain sign" or asymmetrical palate elevation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of NPC:** Fossa of Rosenmüller. * **Most common cranial nerve involved in NPC:** VI nerve (Abducens), leading to diplopia. * **EBV Association:** Nasopharyngeal carcinoma (Type II and III) is strongly linked to the Epstein-Barr Virus. * **Treatment of Choice:** Radiotherapy is the primary treatment for NPC, as it is highly radiosensitive. Surgery is generally reserved for salvage.

Question 93: Which of the following is the most radiosensitive tumor?

A. Supraglottic carcinoma
B. Carcinoma of the glottis
C. Carcinoma of the nasopharynx (Correct Answer)
D. Subglottic carcinoma

Explanation: **Explanation:** The correct answer is **Carcinoma of the nasopharynx (NPC)**. The radiosensitivity of a tumor is largely determined by its histological type and degree of differentiation. Nasopharyngeal carcinoma, particularly the **WHO Type 3 (Undifferentiated/Lymphoepithelioma)**, is highly cellular with a high mitotic index. In oncology, the "Law of Bergonié and Tribondeau" states that cells that are rapidly dividing and poorly differentiated are more sensitive to ionizing radiation. Because NPC is often undifferentiated and associated with Epstein-Barr Virus (EBV), it responds exquisitely well to radiotherapy, which is the primary treatment modality for all stages of the disease. **Analysis of Incorrect Options:** * **Supraglottic and Subglottic Carcinomas:** These are typically **Squamous Cell Carcinomas (SCC)**. While they are radioresponsive, they are generally well-to-moderately differentiated compared to NPC, making them less radiosensitive. * **Carcinoma of the Glottis:** Early-stage glottic cancer is often treated with radiotherapy with excellent results due to its location, but the intrinsic biological sensitivity of the keratinizing SCC found here is lower than that of the undifferentiated cells in the nasopharynx. **High-Yield Clinical Pearls for NEET-PG:** * **Treatment of Choice:** Radiotherapy (RT) is the primary treatment for NPC. For advanced stages, Concurrent Chemo-radiotherapy (CCRT) is used. * **Fossa of Rosenmüller:** The most common site of origin for NPC. * **Trotter’s Triad:** Conductive deafness, Ipsilateral temporoparietal neuralgia (CN V), and Palatal paralysis (CN X)—highly suggestive of NPC. * **EBV Association:** Type 2 and Type 3 NPC have a strong correlation with EBV titers (Anti-VCA antibodies).

Question 94: What are the clinical features of nasopharyngeal angiogibroma?

A. Adolescent male, Epistaxis and nasal obstruction are the cardinal symptoms, Arises from the posterior nasal cavity (Correct Answer)
B. Adolescent male, Epistaxis and nasal obstruction are the cardinal symptoms
C. 3rd to 4th decades, Radiotherapy is the Rx of choice
D. 3rd to 4th decades, Arises from the posterior nasal cavity

Explanation: **Juvenile Nasopharyngeal Angiofibroma (JNA)** is a benign but locally aggressive, highly vascular tumor. It is a classic "high-yield" topic for NEET-PG due to its specific demographic and clinical presentation. ### **Explanation of the Correct Option (A)** * **Demographics:** JNA almost exclusively affects **adolescent males** (typically 10–20 years old). It is testosterone-dependent; hence, it is rarely seen in females. * **Cardinal Symptoms:** The classic presentation is a triad of **painless, progressive nasal obstruction** and **profuse, recurrent epistaxis** (often spontaneous). * **Site of Origin:** It characteristically arises from the **sphenopalatine foramen** (located at the posterior end of the middle turbinate/posterior nasal cavity). ### **Why Other Options are Incorrect** * **Option B:** While it correctly identifies the demographic and symptoms, it is less comprehensive than Option A, which includes the crucial anatomical site of origin. * **Options C & D:** These are incorrect because JNA is a disease of **adolescence**, not the 3rd or 4th decades. Furthermore, **Surgery** (preceded by embolization) is the treatment of choice; Radiotherapy is reserved only for inoperable or intracranial residual tumors. ### **High-Yield Clinical Pearls for NEET-PG** * **Holman-Miller Sign (Antral Sign):** Anterior bowing of the posterior wall of the maxillary sinus seen on CT/MRI. * **Diagnosis:** Diagnosis is primarily **clinical and radiological**. **Biopsy is strictly contraindicated** in the OPD due to the risk of torrential, life-threatening hemorrhage. * **Blood Supply:** The most common feeding vessel is the **Internal Maxillary Artery** (branch of the External Carotid). * **Frog Face Deformity:** Seen in advanced cases due to widening of the nasal bridge and proptosis.

Question 95: Second primary malignancy of the head and neck is commonly associated with which of the following?

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

Explanation: **Explanation:** The occurrence of a second primary malignancy (SPM) in head and neck squamous cell carcinoma (HNSCC) is explained by the concept of **"Field Cancerization."** This theory suggests that the entire mucosal surface of the upper aerodigestive tract is exposed to the same chronic carcinogens (primarily tobacco and alcohol), leading to multiple independent premalignant foci and a higher risk of synchronous or metachronous tumors. **Why Oral Cavity is Correct:** Statistically, the **oral cavity** is the most common site for a second primary malignancy in the head and neck. Patients with an initial index tumor in the oral cavity have the highest annual incidence rate of developing a second primary (approximately 3–7% per year). This is largely due to the extensive surface area exposed to topical carcinogens and the high prevalence of premalignant lesions (like leukoplakia) in this region. **Analysis of Other Options:** * **Hypopharynx & Larynx:** While these sites are frequently involved in field cancerization, the statistical frequency of SPMs originating from or occurring after an index tumor in these locations is lower than that of the oral cavity. * **Paranasal Sinuses:** These are rarely associated with field cancerization. Malignancies here are more often linked to specific occupational exposures (e.g., wood dust) rather than the generalized tobacco-alcohol field effect seen in the oral cavity. **High-Yield Clinical Pearls for NEET-PG:** * **Field Cancerization:** Term coined by Slaughter et al. (1953). * **Definition of SPM:** A second tumor must be histologically different or separated from the primary by at least 2 cm of normal mucosa (if occurring within 3 years). * **Synchronous vs. Metachronous:** Synchronous tumors are detected at the same time or within 6 months; metachronous tumors are detected after 6 months. * **Most common site for distant SPM:** The **Lung** is the most common site for a second primary outside the head and neck region.

Question 96: What is the preferred treatment for a 60-year-old patient with maxillary carcinoma involving the anterolateral part of the maxilla?

A. Radiotherapy only
B. Total/extended maxillectomy followed by radiotherapy
C. Radiotherapy followed by total/extended maxillectomy (Correct Answer)
D. Total/extended maxillectomy alone

Explanation: **Explanation:** The management of maxillary sinus carcinoma (most commonly Squamous Cell Carcinoma) depends on the stage and extent of the disease. For advanced or clinically significant tumors involving the bony walls of the maxilla, a **multimodal approach** is the gold standard. **1. Why Option C is Correct:** The traditional and most effective protocol for resectable maxillary carcinoma is **planned combined therapy**. Historically, the sequence of **Pre-operative Radiotherapy followed by Surgery (Total/Extended Maxillectomy)** was preferred. Pre-operative RT helps in shrinking the tumor mass, sealing lymphatics, and reducing the risk of local recurrence by "sterilizing" the surgical margins. While modern protocols often use surgery followed by post-operative RT, in the context of standard ENT oncology teaching for exams like NEET-PG, the combined approach (specifically RT followed by surgery) is recognized for achieving better local control in advanced cases. **2. Why Other Options are Incorrect:** * **Option A (RT only):** Radiotherapy alone is generally reserved for palliative cases or patients unfit for surgery. Maxillary tumors are often radioresistant due to bony involvement. * **Option D (Surgery alone):** Surgery alone has high recurrence rates because these tumors are often diagnosed at an advanced stage (Ohngren’s line) where microscopic spread is likely. * **Option B (Surgery followed by RT):** While common in modern practice (Post-op RT), classic teaching emphasizes that pre-operative RT (Option C) provides better initial tumor debulking for extensive maxillary lesions. **Clinical Pearls for NEET-PG:** * **Ohngren’s Line:** An imaginary line connecting the medial canthus to the angle of the mandible. Tumors **posterosuperior** to this line have a worse prognosis. * **Most common histology:** Squamous Cell Carcinoma (80%). * **Most common site:** Maxillary sinus (Antrum). * **Dutton’s/Lederman’s Classification:** Used for staging based on anatomical lines (infrastructure, mesostructure, and suprastructure).

Question 97: What is the most common presentation of nasopharyngeal carcinoma?

A. Neck mass (Correct Answer)
B. Trotter's triad
C. Ophthalmoplegia
D. Glue ear

Explanation: **Explanation:** Nasopharyngeal Carcinoma (NPC) is a unique head and neck malignancy with a strong association with the **Epstein-Barr Virus (EBV)**. **1. Why "Neck Mass" is correct:** The most common presenting symptom of NPC (seen in approximately **60–80% of cases**) is a **painless neck mass**, typically involving the upper deep cervical (Level II) lymph nodes. This occurs because the nasopharynx has an extremely rich lymphatic network, leading to early lymphatic spread, often before the primary tumor causes local symptoms. **2. Analysis of Incorrect Options:** * **B. Trotter’s Triad:** This is a classic diagnostic triad for NPC consisting of: (1) Conductive deafness (due to Eustachian tube blockage), (2) Ipsilateral facial/trigeminal pain, and (3) Palatal paralysis. While pathognomonic, it represents advanced local spread and is not the *most common* initial presentation. * **C. Ophthalmoplegia:** This occurs due to the involvement of cranial nerves (III, IV, VI) via the cavernous sinus or superior orbital fissure. It indicates advanced stage disease (T4). * **D. Glue Ear (Otitis Media with Effusion):** While a very common early sign due to Eustachian tube obstruction at the Fossa of Rosenmüller, it is statistically less frequent as the *primary* presenting complaint compared to a neck mass. **Clinical Pearls for NEET-PG:** * **Fossa of Rosenmüller:** The most common site of origin for NPC. * **Unilateral Serous Otitis Media** in an adult is NPC until proven otherwise. * **Treatment of Choice:** Radiotherapy (NPC is highly radiosensitive). Surgery is generally reserved for salvage. * **Histology:** The WHO Type 3 (Undifferentiated) is the most common and has the strongest link to EBV.

Question 98: What is the cause of unilateral secretory otitis media in an adult?

A. Chronic suppurative otitis media (CSOM)
B. Nasopharyngeal carcinoma (Correct Answer)
C. Mastoiditis
D. Foreign body of the external ear

Explanation: **Explanation:** In an adult, **unilateral secretory otitis media (SOM)**—also known as Otitis Media with Effusion (OME)—is considered **nasopharyngeal carcinoma (NPC)** until proven otherwise. **Why Nasopharyngeal Carcinoma is correct:** The nasopharynx is the site of the opening of the **Eustachian tube (ET)**, specifically within the Fossa of Rosenmüller. A tumor in this region can mechanically obstruct the ET orifice. This obstruction leads to negative middle ear pressure, followed by the transudation of fluid into the middle ear cleft, resulting in unilateral hearing loss and effusion. In adults, this presentation is a classic "red flag" for malignancy. **Why other options are incorrect:** * **A. CSOM:** This involves a chronic infection with a perforated tympanic membrane and active or inactive discharge, rather than a sterile collection of fluid behind an intact drum. * **C. Mastoiditis:** This is a complication of acute otitis media characterized by retroauricular pain, fever, and swelling; it is an inflammatory process rather than a primary cause of chronic secretory effusion. * **D. Foreign body:** While it may cause conductive hearing loss or external otitis, it does not affect the Eustachian tube function or lead to middle ear effusion. **High-Yield Clinical Pearls for NEET-PG:** * **Trotter’s Triad for NPC:** 1. Conductive hearing loss (due to SOM), 2. Ipsilateral facial/temporoparietal pain (Trigeminal nerve involvement), 3. Palatal paralysis (Vagus nerve involvement). * **Diagnostic Gold Standard:** Endoscopic examination of the nasopharynx and biopsy. * **Risk Factor:** Strong association with **Epstein-Barr Virus (EBV)**. * **Rule:** Any adult with persistent unilateral ear fullness must undergo a fiberoptic nasopharyngoscopy to rule out NPC.

Question 99: A 50-year-old male presents with right-sided serous otitis media and a history of cervical lymphadenopathy. The probable diagnosis is?

A. Tonsillar abscess
B. Nasopharyngeal cancer (Correct Answer)
C. Angiofibroma
D. Adenoid hypertrophy

Explanation: ***Nasopharyngeal cancer***- Presents classically with the triad of **nasal obstruction/epistaxis**, **unilateral serous otitis media** (due to **Eustachian tube obstruction** by the tumor), and **cervical lymphadenopathy** (often metastatic).- The patient's presentation (adult age, unilateral SOM, and history of metastatic lymphadenopathy) is highly suggestive of this malignancy. *Angiofibroma*- This is a highly **vascular benign tumor** almost exclusively found in **adolescent males**, which contradicts the patient's age (50).- Primary symptoms are severe, recurrent **epistaxis** and nasal obstruction, rather than chronic serous otitis media as the dominant feature. *Adenoid hypertrophy*- While it commonly causes serous otitis media by blocking the **Eustachian tube opening**, it is a disease of **children** and is extremely rare to present *de novo* in a 50-year-old adult.- It typically causes **bilateral symptoms** (SOM, snoring) and is not associated with regional metastatic **cervical lymphadenopathy** in this age group. *Tonsillar abscess*- Symptoms typically include severe **sore throat**, **trismus** (difficulty opening the mouth), and a **"hot-potato" voice**, indicating an acute infection.- This is an acute condition that does not typically cause chronic unilateral serous otitis media as its primary or only otologic manifestation.

Question 100: Human papillomavirus (HPV) infection is most strongly associated with which of the following head and neck cancers?

A. Laryngeal carcinoma
B. Hypopharyngeal carcinoma
C. Oropharyngeal carcinoma (Correct Answer)
D. Nasopharyngeal carcinoma

Explanation: ***Oropharyngeal carcinoma***- HPV (high-risk types, especially **HPV-16**) is the primary etiologic agent for a distinct and increasing subtype of **oropharyngeal squamous cell carcinoma (OPSCC)**, mainly affecting the tonsils and base of the tongue.- HPV-positive OPCs are biologically distinct from those caused by tobacco and alcohol, typically present in younger patients, and have a significantly improved prognosis.*Nasopharyngeal carcinoma*- The strongest viral association with nasopharyngeal carcinoma (NPC) is the **Epstein-Barr virus (EBV)**, not HPV.- NPC is also strongly linked to dietary factors (salted fish) and genetic predisposition, often showing a different geographic distribution.*Hypopharyngeal carcinoma*- This cancer is predominantly caused by heavy use of tobacco and alcohol, placing it firmly in the category of traditional **squamous cell carcinoma** risk factors.- HPV positivity in hypopharyngeal cancers is rare and not considered a major causative factor.*Laryngeal carcinoma*- Laryngeal squamous cell carcinoma is overwhelmingly associated with **tobacco smoking** and, secondarily, alcohol use.- While HPV can cause laryngeal papillomatosis, its definitive causal role in invasive laryngeal *carcinoma* is weak and inconsistent compared to its strong association with the oropharynx.

Practice by Chapter

Staging of Head and Neck Cancer

Practice Questions

Oral Cavity Cancer

Practice Questions

Oropharyngeal Cancer and HPV

Practice Questions

Laryngeal Cancer

Practice Questions

Hypopharyngeal Cancer

Practice Questions

Sinonasal Malignancies

Practice Questions

Salivary Gland Neoplasms

Practice Questions

Thyroid Cancer

Practice Questions

Paragangliomas

Practice Questions

Principles of Radiation Therapy

Practice Questions

Chemotherapy and Targeted Therapy

Practice Questions

Surveillance and Survivorship

Practice Questions

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