ENT Oncology — MCQs
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What is the causative agent of oropharyngeal carcinoma?
A patient complains of difficulty breathing through his nose and bony pain in his cheeks, near his nose. Physical examination and CT of the head reveal mass lesions involving the nose, pharynx, and sinuses. CT-guided biopsy demonstrates a non-keratinizing, squamous cell carcinoma. Which of the following disorders is associated with the same oncogenic virus that is the likely cause of this patient's cancer?
A 16-year-old boy presents with nasal obstruction. Nasopharyngeal endoscopy reveals a tumor. Histology confirms a juvenile nasopharyngeal hemangioma. What is characteristic of this lesion?
Trismus in oral cancer patients is severe in those treated with which combination of modalities?
Which one of the following conditions is considered to be definitely precancerous in the larynx?
A glomus tumor is invading the vertical part of the carotid canal. What type is it?
What is the primary treatment for nasopharyngeal angiofibroma?
Sinonasal neoplasms are commonly associated with which industrial exposure?
What is the treatment of choice for T2 carcinoma of the nasopharynx?
A 55-year-old smoker presents with a low-pitched voice. Endoscopy reveals a mass limited to the left vocal cord. Biopsy is suggestive of laryngeal cancer, T1N0. What is the treatment of choice?
ENT Oncology Indian Medical PG Practice Questions and MCQs
Question 11: What is the causative agent of oropharyngeal carcinoma?
- A. Hepatitis B virus (HBV)
- B. Cytomegalovirus (CMV)
- C. Herpes simplex virus (HSV)
- D. Human papillomavirus (HPV) (Correct Answer)
Explanation: ### Explanation **Correct Answer: D. Human papillomavirus (HPV)** The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has shifted significantly over the last decade. While tobacco and alcohol were historically the primary risk factors, **Human Papillomavirus (HPV)**, specifically **high-risk strain 16**, is now the leading cause of oropharyngeal cancer (especially involving the palatine tonsils and base of tongue). The underlying mechanism involves the viral oncoproteins **E6 and E7**, which inactivate the host’s tumor suppressor proteins **p53 and Rb**, respectively, leading to malignant transformation. **Why other options are incorrect:** * **Hepatitis B virus (HBV):** Primarily associated with Hepatocellular Carcinoma (HCC); it has no established role in head and neck oncology. * **Cytomegalovirus (CMV):** While a common opportunistic pathogen in immunocompromised patients, it is not considered an oncogenic virus for oropharyngeal cancer. * **Herpes simplex virus (HSV):** Associated with oral lesions (herpetic gingivostomatitis) and encephalitis, but not linked to the pathogenesis of oropharyngeal malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Site Predilection:** HPV-associated cancers typically occur in the **tonsillar crypts** and **lingual tonsils**. * **Prognosis:** HPV-positive oropharyngeal cancers generally have a **better prognosis** and better response to radiotherapy/chemotherapy compared to HPV-negative (tobacco-related) cancers. * **Surrogate Marker:** **p16 immunohistochemistry (IHC)** is used as a reliable surrogate marker for HPV infection in clinical practice. * **Staging:** Due to the better prognosis, the AJCC 8th Edition has a separate staging system for HPV-mediated (p16+) oropharyngeal cancer.
Question 12: A patient complains of difficulty breathing through his nose and bony pain in his cheeks, near his nose. Physical examination and CT of the head reveal mass lesions involving the nose, pharynx, and sinuses. CT-guided biopsy demonstrates a non-keratinizing, squamous cell carcinoma. Which of the following disorders is associated with the same oncogenic virus that is the likely cause of this patient's cancer?
- A. Adult T-cell leukemia
- B. Burkitt's lymphoma (Correct Answer)
- C. Cervical carcinoma
- D. Hepatocellular carcinoma
Explanation: **Explanation:** The patient presents with symptoms and biopsy findings (non-keratinizing squamous cell carcinoma of the nasopharynx) diagnostic of **Nasopharyngeal Carcinoma (NPC)**. NPC is strongly associated with the **Epstein-Barr Virus (EBV)**, particularly the undifferentiated (Type 3) and non-keratinizing (Type 2) subtypes. **Why Burkitt’s Lymphoma is correct:** Burkitt’s lymphoma is also etiologically linked to **EBV**. The virus infects B-cells via the CD21 receptor, leading to malignant transformation. In the endemic (African) form of Burkitt’s lymphoma, EBV is found in nearly 100% of cases. Therefore, it shares the same oncogenic driver as NPC. **Analysis of Incorrect Options:** * **A. Adult T-cell leukemia:** Caused by **HTLV-1** (Human T-lymphotropic virus 1). * **C. Cervical carcinoma:** Primarily caused by high-risk strains of **HPV** (Human Papillomavirus), specifically types 16 and 18. * **D. Hepatocellular carcinoma:** Associated with chronic infection by **Hepatitis B (HBV)** and **Hepatitis C (HCV)** viruses. **Clinical Pearls for NEET-PG:** * **NPC Triad (Trotter’s Triad):** Conductive hearing loss (due to Eustachian tube blockage), Palatal paralysis, and Trigeminal neuralgia. * **EBV Associations:** Infectious Mononucleosis, Nasopharyngeal Carcinoma, Burkitt’s Lymphoma, Hodgkin’s Lymphoma (Mixed cellularity), and Oral Hairy Leukoplakia (in HIV). * **Bimodal Age Distribution:** NPC often shows peaks in the 2nd and 6th decades of life. * **Tumor Marker:** Plasma EBV DNA levels are used for monitoring treatment response and recurrence in NPC.
Question 13: A 16-year-old boy presents with nasal obstruction. Nasopharyngeal endoscopy reveals a tumor. Histology confirms a juvenile nasopharyngeal hemangioma. What is characteristic of this lesion?
- A. It is a premalignant lesion.
- B. It is associated with laryngeal obstruction.
- C. It is primarily treated with radiotherapy.
- D. It can infiltrate and destroy surrounding bone. (Correct Answer)
Explanation: ### **Explanation** **Juvenile Nasopharyngeal Angiofibroma (JNA)** is a benign but locally aggressive, highly vascular tumor that typically occurs in adolescent males. **1. Why Option D is Correct:** Although histologically benign (it does not metastasize), JNA is characterized by **local invasiveness**. It originates near the sphenopalatine foramen and grows by expanding and pressure-eroding the surrounding bony structures. It can destroy the walls of the maxillary sinus, the pterygoid plates, and even the skull base, leading to intracranial extension. **2. Why the Other Options are Incorrect:** * **Option A:** JNA is a **completely benign** vascular tumor. It does not have a risk of malignant transformation. * **Option B:** The primary symptoms are **painless, profuse epistaxis** and **nasal obstruction**. While it can grow large enough to fill the nasopharynx and push the soft palate downward, it does not typically cause laryngeal obstruction. * **Option C:** The treatment of choice is **surgical excision** (often preceded by preoperative embolization to reduce bleeding). Radiotherapy is reserved only for recurrent cases or extensive tumors with intracranial involvement where surgery is not feasible. --- ### **High-Yield Clinical Pearls for NEET-PG** * **Demographics:** Almost exclusively seen in **adolescent males** (testosterone-dependent). * **Classic Triad:** Adolescent male + Nasal obstruction + Recurrent profuse epistaxis. * **Holman-Miller Sign (Antral Sign):** Forward bowing of the posterior wall of the maxillary sinus seen on CT/MRI (Pathognomonic). * **Diagnosis:** Biopsy is **contraindicated** due to the risk of torrential hemorrhage. Diagnosis is clinical and radiological. * **Blood Supply:** Most commonly the **Internal Maxillary Artery** (branch of the External Carotid).
Question 14: Trismus in oral cancer patients is severe in those treated with which combination of modalities?
- A. Surgery and Radiotherapy (Correct Answer)
- B. Chemotherapy alone
- C. Surgery alone
- D. Not related to treatment
Explanation: **Explanation:** **Trismus** (restricted mouth opening) in oral cancer is a multifactorial complication resulting from both the disease process and its management. **Why Surgery and Radiotherapy is the correct answer:** The combination of **Surgery and Radiotherapy (RT)** is the most potent cause of severe trismus. 1. **Surgery:** Surgical resection, especially involving the posterior oral cavity, retromolar trigone, or masticatory muscles (medial and lateral pterygoids), leads to the formation of inelastic scar tissue and wound contraction. 2. **Radiotherapy:** RT induces **microvascular damage and progressive fibrosis** of the masticatory muscles and the Temporomandibular Joint (TMJ) capsule. When combined, the surgical scarring is further exacerbated by radiation-induced fibrosis, leading to a synergistic effect that severely restricts mandibular mobility. **Analysis of Incorrect Options:** * **B. Chemotherapy alone:** While chemotherapy can cause mucositis and pain (pseudotrismus), it does not typically cause permanent structural fibrosis or mechanical restriction of the joint. * **C. Surgery alone:** While surgery causes scarring, without the added "woody" fibrosis induced by radiation, the resulting trismus is generally less severe and more amenable to physical therapy. * **D. Not related to treatment:** This is incorrect as trismus is a well-documented late sequela of head and neck cancer therapy. **Clinical Pearls for NEET-PG:** * **Most common muscle involved:** The **Medial Pterygoid** is the muscle most frequently implicated in post-radiation trismus. * **Measurement:** Trismus is clinically defined as an inter-incisor distance of **<35 mm**. * **High-Yield Fact:** The risk of trismus increases significantly if the dose to the pterygoid muscles or TMJ exceeds **60 Gy**. * **Management:** Early jaw-stretching exercises (e.g., using a Heister’s opening or TheraBite device) are crucial during and after treatment.
Question 15: Which one of the following conditions is considered to be definitely precancerous in the larynx?
- A. Vocal nodules
- B. Subglottic hemangiomas
- C. Leukoplakia (Correct Answer)
- D. Vocal polyp
Explanation: **Explanation:** **Leukoplakia** is the correct answer because it is a clinical term for a white patch on the mucosal surface that cannot be characterized clinically or pathologically as any other disease. In the larynx, it represents a spectrum of epithelial changes ranging from simple hyperplasia and hyperkeratosis to **dysplasia**, carcinoma-in-situ, and invasive squamous cell carcinoma. Histologically, the presence of dysplasia is the most significant predictor of malignant transformation, making it a definitive precancerous condition. **Why the other options are incorrect:** * **Vocal Nodules:** These are benign, inflammatory reactive lesions (usually bilateral) caused by mechanical trauma from vocal abuse (Screamer’s nodes). They have no malignant potential. * **Vocal Polyps:** These are unilateral inflammatory lesions resulting from acute vocal trauma or smoking. Like nodules, they are benign and do not undergo malignant transformation. * **Subglottic Hemangiomas:** These are benign vascular tumors, most commonly seen in infants. While they can cause airway obstruction, they are not neoplastic precursors to laryngeal cancer. **NEET-PG High-Yield Pearls:** * **Pachydermia Laryngis:** A form of chronic hypertrophic laryngitis (often due to GERD) characterized by interarytenoid thickening; it is generally **not** considered precancerous. * **Adult-Onset Recurrent Respiratory Papillomatosis (RRP):** Caused by HPV 6 and 11; it has a small but documented risk of malignant transformation (unlike the juvenile form). * **Erythroplakia:** Though less common than leukoplakia in the larynx, a red velvety patch (erythroplakia) carries a significantly **higher risk** of harboring malignancy at the time of biopsy. * **Main Risk Factors:** Smoking and alcohol consumption are the primary synergistic triggers for laryngeal precancerous lesions.
Question 16: A glomus tumor is invading the vertical part of the carotid canal. What type is it?
- A. Type B
- B. Type CI
- C. Type C2 (Correct Answer)
- D. Type C3
Explanation: This question refers to the **Fisch Classification** of Glomus tumors (Paragangliomas), which is the gold standard for determining the extent of these vascular tumors and planning surgical management. ### **Explanation of the Correct Answer** The Fisch classification categorizes tumors based on their extension into the temporal bone and skull base. **Type C** tumors specifically involve the **infralabyrinthine compartment** and extend along the **carotid canal**. * **Type C1:** Destroys the bone around the vertical portion of the carotid canal but does not invade the artery's lumen or the canal itself extensively. * **Type C2:** Specifically involves **invasion of the vertical part of the carotid canal**. * **Type C3:** Involves the **horizontal part** of the carotid canal. Since the question specifies invasion of the vertical part of the carotid canal, **Type C2** is the correct classification. ### **Analysis of Incorrect Options** * **Type B:** These tumors are limited to the tympanomastoid area without involvement of the infralabyrinthine compartment or the carotid canal. * **Type CI:** As noted above, this involves only the apex of the carotid foramen but does not track up the vertical canal. * **Type C3:** This represents more advanced disease involving the horizontal segment of the internal carotid artery (ICA) toward the foramen lacerum. ### **NEET-PG High-Yield Pearls** * **Fisch Type A:** Limited to the middle ear (Glomus Tympanicum). * **Fisch Type D:** Represents intracranial extension (D1: <2cm; D2: >2cm). * **Clinical Signs:** Look for **Pulsatile Tinnitus** and a **"Rising Sun" appearance** on otoscopy. * **Brown’s Sign:** Blanching of the tumor on positive pressure with a Siegel’s speculum (Pathognomonic). * **Phelps Sign:** Loss of the bony crest between the carotid canal and jugular bulb on CT.
Question 17: What is the primary treatment for nasopharyngeal angiofibroma?
- A. Surgery (Correct Answer)
- B. Radiotherapy
- C. Chemotherapy
- D. Observation
Explanation: **Explanation:** **Juvenile Nasopharyngeal Angiofibroma (JNA)** is a benign but locally aggressive, highly vascular tumor primarily affecting adolescent males. **1. Why Surgery is the Correct Answer:** **Surgery** is the definitive and primary treatment of choice. The goal is complete surgical excision to prevent local destruction and recurrence. Modern approaches often utilize **Endoscopic Endonasal Surgery** for smaller tumors (Fisch Stage I/II) or open approaches (like the Weber-Fergusson or Transpalatal approach) for larger extensions. To minimize intraoperative blood loss—the most significant surgical risk—**pre-operative selective embolization** (usually of the Internal Maxillary Artery) is performed 24–48 hours before the procedure. **2. Why Other Options are Incorrect:** * **Radiotherapy:** Reserved as a second-line treatment for inoperable cases, intracranial extension, or recurrent tumors, due to the risk of secondary malignancies and growth retardation in young patients. * **Chemotherapy:** Has no established role as a primary treatment; it is occasionally used for palliative care in advanced systemic disease. * **Observation:** JNA is locally invasive and can erode the skull base; therefore, "watchful waiting" is inappropriate unless the patient is medically unfit for any intervention. **Clinical Pearls for NEET-PG:** * **Origin:** Sphenopalatine foramen (specifically the posterior aspect of the nasal cavity). * **Classic Triad:** Adolescent male + Profuse recurrent epistaxis + Nasal obstruction. * **Holman-Miller Sign (Antral Sign):** Anterior bowing of the posterior wall of the maxillary sinus seen on CT/MRI (Pathognomonic). * **Biopsy is Contraindicated:** Due to the extreme risk of torrential hemorrhage. Diagnosis is clinical and radiological.
Question 18: Sinonasal neoplasms are commonly associated with which industrial exposure?
- A. Fishing
- B. Building/Construction
- C. Hardwood industry (Correct Answer)
- D. Iron and steel industry
Explanation: **Explanation:** The association between occupational exposures and sinonasal malignancies is a classic high-yield topic in ENT oncology. **1. Why Hardwood Industry is Correct:** Exposure to **hardwood dust** (e.g., beech and oak) is strongly linked to the development of **Sinonasal Adenocarcinoma**, specifically the intestinal type. The fine dust particles act as chronic irritants and carcinogens when inhaled, often settling in the ethmoid sinuses. This association is so strong that it is recognized as a professional hazard in the woodworking and furniture-making industries. **2. Analysis of Incorrect Options:** * **Fishing:** There is no established epidemiological link between the fishing industry and sinonasal neoplasms. * **Building/Construction:** While construction involves various dusts, it is more classically associated with **Asbestosis** and **Mesothelioma** (pleural/peritoneal) rather than primary sinonasal adenocarcinoma. * **Iron and Steel Industry:** Exposure here is more commonly linked to lung cancers due to heavy metals and coke oven emissions, rather than the specific pathology of sinonasal adenocarcinoma. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Site:** The **Ethmoid sinus** is the most common site for wood-dust-related adenocarcinoma. * **Nickel Exposure:** Associated with **Squamous Cell Carcinoma** of the nasal cavity and sinuses. * **Softwood Dust:** While also a risk, hardwood carries a significantly higher relative risk for adenocarcinoma. * **Radon/Thorotrast:** Historically linked to Maxillary sinus carcinomas. * **Isopropanol manufacture:** Another industrial risk factor for paranasal sinus tumors. * **Latency:** These tumors often have a long latency period (20–40 years) post-exposure.
Question 19: What is the treatment of choice for T2 carcinoma of the nasopharynx?
- A. Surgery
- B. Radiotherapy (Correct Answer)
- C. Chemotherapy
- D. Surgery + postoperative radiotherapy
Explanation: **Explanation:** **Nasopharyngeal Carcinoma (NPC)** is unique among head and neck cancers due to its anatomical location, strong association with the **Epstein-Barr Virus (EBV)**, and high degree of radiosensitivity. 1. **Why Radiotherapy is the Correct Answer:** The primary treatment for NPC across almost all stages is **Radiotherapy (RT)**. The nasopharynx is surgically inaccessible for wide-margin resections, and the tumor is highly sensitive to radiation. For **T2 lesions** (tumor extending to the soft tissue of the oropharynx or nasal cavity), RT remains the mainstay. While advanced stages (T3, T4, or N+) often require concurrent Chemoradiotherapy (CCRT), RT alone or CCRT is the standard of care. 2. **Why Other Options are Incorrect:** * **Surgery (A & D):** The nasopharynx is located deep in the skull base, surrounded by vital neurovascular structures, making primary surgical resection technically difficult and morbid. Surgery is reserved only for **salvage** in cases of recurrence or persistent localized disease. * **Chemotherapy (C):** NPC is chemosensitive, but chemotherapy is never used as a standalone curative treatment. It is used as an adjunct (neoadjuvant, concurrent, or adjuvant) to radiotherapy to improve survival in locally advanced cases. **High-Yield Clinical Pearls for NEET-PG:** * **Treatment of Choice:** RT is the treatment of choice for Stage I; CCRT is the standard for Stage II to IVB. * **Most Common Site:** Fossa of Rosenmüller. * **Most Common Histology:** Undifferentiated Squamous Cell Carcinoma (WHO Type 3) – this type has the strongest link to EBV and the best prognosis due to high radiosensitivity. * **Clinical Presentation:** Often presents with the **Trotter’s Triad**: (1) Conductive hearing loss (due to Eustachian tube blockage), (2) Ipsilateral facial pain/paresthesia (Trigeminal nerve involvement), and (3) Palatal paralysis.
Question 20: A 55-year-old smoker presents with a low-pitched voice. Endoscopy reveals a mass limited to the left vocal cord. Biopsy is suggestive of laryngeal cancer, T1N0. What is the treatment of choice?
- A. Vertical partial hemilaryngectomy
- B. Radiotherapy (Correct Answer)
- C. Chemotherapy
- D. Total laryngectomy with cervical lymph node dissection
Explanation: **Explanation:** The patient presents with **Early Glottic Cancer (T1N0M0)**, where the tumor is limited to the vocal cord with normal mobility. The primary goal in treating early laryngeal cancer is **cure with organ preservation** and maintenance of voice quality. **1. Why Radiotherapy (RT) is the Correct Choice:** For T1 glottic lesions, both **Radiotherapy** and **Endoscopic Laser Excision** (Transoral Laser Microsurgery - TLM) are considered standard treatments of choice, offering excellent local control rates (>90%). RT is often preferred when the lesion involves the anterior commissure or when a superior functional voice outcome is desired, as it preserves the mucosal wave better than surgical excision. **2. Why Other Options are Incorrect:** * **Vertical Partial Hemilaryngectomy:** This is an open surgical procedure. While oncologically sound, it is more invasive than RT or TLM and is generally reserved for specific recurrences or cases where endoscopic access is impossible. * **Chemotherapy:** Chemotherapy is not used as a primary single-modality treatment for early-stage (T1-T2) laryngeal cancer. It is typically reserved for advanced stages (T3-T4) as part of concurrent chemoradiotherapy (organ preservation protocols). * **Total Laryngectomy with Neck Dissection:** This is a radical, mutilating surgery reserved for advanced (T4a) disease or salvage after failed radiotherapy. It is contraindicated in T1 disease where the larynx can be easily saved. **Clinical Pearls for NEET-PG:** * **T1a:** Tumor limited to one vocal cord. * **T1b:** Tumor involves both vocal cords. * **T2:** Tumor extends to supraglottis/subglottis or impaired cord mobility (but not fixed). * **T3:** Vocal cord fixation (requires RT/Chemo or surgery). * **Most common site** of laryngeal cancer: **Glottis** (best prognosis due to sparse lymphatics). * **Most common pathology:** Squamous Cell Carcinoma.
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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