ENT Oncology — MCQs
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A 54-year-old man, a nonsmoker, presents with a 2-month history of a nonhealing ulceration at the base of his tongue on the right side. Examination reveals a 1 cm diameter lesion with irregular borders. A biopsy shows infiltrating squamous cell carcinoma. Which of the following infectious agents is most likely to be associated with this lesion?
Horner's syndrome is caused by which of the following?
Nasopharyngeal angiofibroma is:
Factors that have been associated with an increased incidence of head and neck carcinomas include all of the following except?
Nasopharyngeal fibroma is composed of vascular and fibrous tissues. What is its characteristic nature?
What are the characteristic features of laryngeal carcinoma?
A 70-year-old male presents with a one-month history of ulceration on the lower lip with lymph node involvement. He has a 30-year history of chewing tobacco 6-7 times daily. The patient also reports unintentional weight loss for two months and a change in voice for one month. Which of the following clinical findings strongly suggests a diagnosis of malignancy?
A biopsy of a reasonably well-demarcated mass of the nasopharynx from a 30-year-old man demonstrates a plasma cell proliferation. Serum electrophoresis shows a small monoclonal IgG spike. Bone marrow evaluation fails to demonstrate plasma cell proliferation, and no lesions are seen on extensive skeletal x-rays. Which of the following is the most likely diagnosis?
Commonest cancer of the oral cavity is?
A 55-year-old chronic smoker presents with complaints of hoarseness of voice and a single enlarged painless lymph node in the left supraclavicular region. What is the next step in management?
ENT Oncology Indian Medical PG Practice Questions and MCQs
Question 31: A 54-year-old man, a nonsmoker, presents with a 2-month history of a nonhealing ulceration at the base of his tongue on the right side. Examination reveals a 1 cm diameter lesion with irregular borders. A biopsy shows infiltrating squamous cell carcinoma. Which of the following infectious agents is most likely to be associated with this lesion?
- A. Candida albicans
- B. Herpes simplex virus (HSV)
- C. Human papillomavirus (HPV) (Correct Answer)
- D. Prevotella intermedia
Explanation: ### Explanation The correct answer is **Human papillomavirus (HPV)**, specifically high-risk types like **HPV-16**. #### Why HPV is Correct The patient presents with Squamous Cell Carcinoma (SCC) of the **base of the tongue**, which is a component of the **oropharynx**. Traditionally, head and neck SCCs were primarily associated with tobacco and alcohol. However, there is a rising incidence of oropharyngeal SCC in **younger, non-smoking patients** driven by HPV infection. HPV-related cancers typically involve the lymphoid tissue of the Waldeyer’s ring (palatine and lingual tonsils/base of tongue). These tumors often have a better prognosis and higher sensitivity to radiotherapy compared to tobacco-induced cancers. #### Why Other Options are Incorrect * **Candida albicans:** While chronic hyperplastic candidiasis (candidal leukoplakia) has a small risk of malignant transformation in the oral cavity, it is not a primary driver of oropharyngeal SCC. * **Herpes simplex virus (HSV):** HSV is associated with painful, self-limiting vesicular eruptions (cold sores) but has no proven oncogenic role in head and neck cancers. * **Prevotella intermedia:** This is a gram-negative anaerobe associated with periodontal disease and Acute Necrotizing Ulcerative Gingivitis (ANUG), not carcinogenesis. #### NEET-PG High-Yield Pearls * **Most common HPV subtype:** HPV-16 is responsible for ~90% of HPV-positive oropharyngeal SCCs. * **Surrogate Marker:** **p16 immunohistochemistry** is used as a reliable surrogate marker for HPV infection in these tumors. * **Staging:** In the AJCC 8th Edition, HPV-positive (p16+) oropharyngeal cancers have a **separate staging system** due to their significantly better survival rates. * **Field Cancerization:** This concept (multiple primary tumors) is more common in tobacco-related SCC than in HPV-related SCC.
Question 32: Horner's syndrome is caused by which of the following?
- A. Nasopharyngeal carcinoma metastasis (Correct Answer)
- B. Facial bone injury
- C. Maxillary sinusitis
- D. Ethmoid polyp
Explanation: **Explanation:** **Why Option A is Correct:** Horner’s syndrome (ptosis, miosis, and anhidrosis) results from an interruption of the **sympathetic chain**. In the context of ENT oncology, Nasopharyngeal Carcinoma (NPC) is notorious for its local and regional spread. The tumor or its metastatic cervical lymph nodes (specifically the **retropharyngeal nodes of Rouviere**) can invade or compress the **cervical sympathetic trunk** located in the parapharyngeal space or near the carotid sheath. This involvement is often associated with advanced disease (Stage IV) and may occur alongside cranial nerve palsies (III, IV, V, and VI) in Trotter’s Triad or Cavernous Sinus Syndrome. **Why Other Options are Incorrect:** * **B. Facial bone injury:** While trauma can cause nerve damage, standard facial bone fractures (like Le Fort or Zygomatic) typically involve the trigeminal or facial nerves. Horner’s syndrome requires injury to the deep neck structures or the apex of the orbit, which is not a routine feature of isolated facial bone trauma. * **C. Maxillary sinusitis:** This is an inflammatory condition confined to the maxillary antrum. It does not involve the sympathetic chain. * **D. Ethmoid polyp:** These are benign mucosal protrusions in the nasal cavity/ethmoid sinuses. They cause nasal obstruction and anosmia but do not extend into the parapharyngeal space to affect sympathetic fibers. **High-Yield Clinical Pearls for NEET-PG:** * **Trotter’s Triad (NPC):** 1. Conductive hearing loss (Eustachian tube blockage), 2. Ipsilateral soft palate paralysis (CN X), 3. Trigeminal neuralgia (CN V). * **Pancoast Tumor:** Another common cause of Horner’s syndrome in exams, involving the sympathetic chain at the lung apex. * **NPC Origin:** Most commonly arises from the **Fossa of Rosenmüller**. * **EBV Association:** Strong correlation with Type II and Type III (Undifferentiated) NPC.
Question 33: Nasopharyngeal angiofibroma is:
- A. Benign (Correct Answer)
- B. Malignant
- C. Benign but potentially malignant
- D. None of the above
Explanation: **Explanation:** **Juvenile Nasopharyngeal Angiofibroma (JNA)** is a histologically **benign** but clinically aggressive tumor. It is the most common benign neoplasm of the nasopharynx, primarily affecting adolescent males. 1. **Why Option A is Correct:** Histologically, JNA consists of a dense fibrous stroma and a rich network of thin-walled vascular channels lacking a muscular coat (tunica media). Despite its aggressive local behavior—such as the ability to erode bone and invade the orbit or cranial fossa—it **does not metastasize**. Therefore, it is classified strictly as a benign tumor. 2. **Why Options B & C are Incorrect:** JNA is not malignant because it lacks cellular atypia, pleomorphism, and the ability to spread to distant sites. Unlike some other benign tumors (e.g., pleomorphic adenoma), JNA has **no documented potential for malignant transformation**. Its "danger" arises from its extreme vascularity and local pressure necrosis, not oncogenic progression. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Exclusively seen in **adolescent males** (testosterone-dependent). * **Origin:** Usually arises from the superior border of the **sphenopalatine foramen**. * **Classic Triad:** Profuse recurrent epistaxis, nasal obstruction, and a mass in the nasopharynx. * **Radiology:** **Holman-Miller Sign** (antral sign) – anterior bowing of the posterior wall of the maxilla seen on CT/MRI. * **Diagnosis:** Biopsy is **contraindicated** due to the risk of torrential hemorrhage. Diagnosis is clinical and radiological. * **Treatment:** Surgical excision (preceded by preoperative embolization to reduce blood loss).
Question 34: Factors that have been associated with an increased incidence of head and neck carcinomas include all of the following except?
- A. Syphilis
- B. Hepatitis B virus (Correct Answer)
- C. Exposure to nickel
- D. Alcohol consumption
Explanation: **Explanation:** The correct answer is **Hepatitis B virus (HBV)**. While HBV is a major risk factor for hepatocellular carcinoma, it has no established causal link with head and neck squamous cell carcinomas (HNSCC). In contrast, other viruses like HPV (Oropharynx) and EBV (Nasopharynx) are strongly associated with head and neck oncology. **Analysis of Options:** * **Syphilis (Option A):** Historically, tertiary syphilis (specifically syphilitic glossitis) was a well-known risk factor for **carcinoma of the anterior two-thirds of the tongue**. Chronic inflammation and the use of arsenicals in older treatments contributed to this association. * **Exposure to Nickel (Option C):** Occupational exposure to heavy metals, particularly **nickel and chromium**, is a high-yield risk factor for **sinonasal adenocarcinoma** and squamous cell carcinoma of the nasal cavity and paranasal sinuses. * **Alcohol Consumption (Option D):** Alcohol acts synergistically with tobacco. It functions as a solvent, increasing the permeability of the oral mucosa to carcinogens, and its metabolite, acetaldehyde, is directly genotoxic. **High-Yield Clinical Pearls for NEET-PG:** 1. **Plummer-Vinson Syndrome:** Associated with an increased risk of post-cricoid carcinoma (Hypopharynx). 2. **Wood Dust Exposure:** Specifically linked to **Adenocarcinoma of the Ethmoid sinus**. 3. **EBV:** Strongly associated with **Nasopharyngeal Carcinoma** (Schmincke's tumor). 4. **HPV (Types 16 & 18):** Now the leading cause of **Oropharyngeal cancer** (especially tonsils and base of tongue) in non-smokers. 5. **Dietary Factors:** Vitamin A and C deficiencies are linked to increased HNSCC risk.
Question 35: Nasopharyngeal fibroma is composed of vascular and fibrous tissues. What is its characteristic nature?
- A. A nasal polyp
- B. A benign lesion
- C. A locally invasive benign lesion (Correct Answer)
- D. A highly malignant lesion
Explanation: **Explanation:** **Nasopharyngeal Angiofibroma (JNA)** is a histologically benign but clinically aggressive tumor. The correct answer is **C (A locally invasive benign lesion)** because, while the tumor does not metastasize (non-malignant), it lacks a true capsule and possesses a notorious ability to erode bone and invade adjacent structures. It typically spreads from the sphenopalatine foramen into the pterygopalatine fossa, infratemporal fossa, orbit, and even the cranial cavity. **Analysis of Incorrect Options:** * **A (Nasal polyp):** Nasal polyps are inflammatory outgrowths of the sinonasal mucosa. JNA is a true neoplastic vascular growth, not an inflammatory polyp. * **B (A benign lesion):** While histologically "benign," this option is incomplete. In NEET-PG, "locally invasive" is the more specific and accurate descriptor for JNA’s clinical behavior. * **D (Highly malignant lesion):** JNA does not show cellular atypia, increased mitosis, or distant metastasis, which are hallmarks of malignancy. **Clinical Pearls for NEET-PG:** * **Demographics:** Exclusively seen in **adolescent males** (testosterone-dependent). * **Classic Triad:** Profuse painless epistaxis, progressive nasal obstruction, and a mass in the nasopharynx. * **Radiology:** **Holman-Miller Sign** (antral sign) is pathognomonic—it shows anterior bowing of the posterior wall of the maxillary sinus on CT/MRI. * **Management:** Surgery is the treatment of choice. **Pre-operative embolization** (24–48 hours prior) is essential to reduce intraoperative bleeding. * **Contraindication:** **Biopsy is strictly contraindicated** in an office setting due to the risk of torrential, life-threatening hemorrhage.
Question 36: What are the characteristic features of laryngeal carcinoma?
- A. The glottis is the most common site.
- B. It commonly metastasizes to cervical lymph nodes.
- C. Lesions are often seen at the edge of the vocal cord.
- D. All of the above. (Correct Answer)
Explanation: Laryngeal carcinoma, predominantly Squamous Cell Carcinoma (SCC), is a high-yield topic in ENT oncology. The correct answer is **D (All of the above)** because each option describes a fundamental clinical characteristic of the disease. **1. Glottis as the Most Common Site:** In most global populations (including India), the glottis (vocal cords) is the most common site for laryngeal cancer (approx. 60-65%), followed by the supraglottis. Glottic tumors often present early due to hoarseness of voice. **2. Cervical Lymph Node Metastasis:** While glottic cancers have sparse lymphatic drainage and rarely metastasize early, laryngeal cancer as a whole—specifically supraglottic and subglottic types—has a high propensity for spread to the deep cervical lymph nodes (Levels II, III, and IV). Supraglottic tumors often present with bilateral nodal involvement due to rich lymphatic networks. **3. Lesion Location:** Glottic lesions typically arise on the **free edge of the anterior two-thirds of the vocal cord**. This anatomical site is a transition zone for epithelium, making it susceptible to carcinogens like tobacco and alcohol. **High-Yield Clinical Pearls for NEET-PG:** * **Best Prognosis:** Glottic SCC (due to early symptoms and poor lymphatics). * **Worst Prognosis:** Subglottic SCC (often silent until advanced). * **Most Common Histology:** Keratinizing Squamous Cell Carcinoma. * **Staging Tip:** "Fixed vocal cord" automatically upgrades a tumor to **T3**. * **Treatment:** Early stages (T1, T2) are treated with radiotherapy or laser excision; advanced stages (T3, T4) usually require total laryngectomy.
Question 37: A 70-year-old male presents with a one-month history of ulceration on the lower lip with lymph node involvement. He has a 30-year history of chewing tobacco 6-7 times daily. The patient also reports unintentional weight loss for two months and a change in voice for one month. Which of the following clinical findings strongly suggests a diagnosis of malignancy?
- A. An ulcerative lesion
- B. An ulcerative and painful lesion
- C. Ulceration and fixation of the lymph node (Correct Answer)
- D. Bilateral involvement of the lymph node
Explanation: ### Explanation **1. Why Option C is Correct:** In the context of a chronic tobacco user with a persistent ulcer, the presence of **fixation of the lymph node** to surrounding structures (skin, mandible, or carotid sheath) is a hallmark of advanced malignancy. Fixation indicates **extracapsular spread (ECS)**, where the tumor cells have breached the lymph node capsule and infiltrated adjacent tissues. In ENT oncology, a fixed, hard, and non-tender lymph node is highly suggestive of metastatic squamous cell carcinoma (SCC) and carries a poorer prognosis (Stage N3 in many TNM classifications). **2. Analysis of Incorrect Options:** * **Option A (An ulcerative lesion):** While malignancy often presents as an ulcer, many benign conditions (e.g., aphthous ulcers, traumatic ulcers, or primary syphilis) also present this way. Ulceration alone is non-specific. * **Option B (An ulcerative and painful lesion):** Malignant ulcers are typically **painless** in the early stages. Pain usually suggests secondary infection or nerve involvement, but it is more characteristic of inflammatory or infectious processes. * **Option D (Bilateral involvement):** While bilateral nodes can occur in malignancy (especially if the lesion crosses the midline), they can also occur in systemic infections (e.g., infectious mononucleosis) or inflammatory conditions. Fixation is a much stronger indicator of malignancy than laterality. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common site for Lip Cancer:** Lower lip (due to sun exposure and tobacco placement). * **Most common pathology:** Squamous Cell Carcinoma (SCC). * **Red Flags for Malignancy:** Persistent ulcer (>3 weeks), "everted" edges, indurated base, and fixed cervical lymphadenopathy. * **Weight loss and Voice change:** In this patient, these symptoms suggest possible synchronous primary tumors or advanced regional spread (e.g., laryngeal involvement), common in heavy tobacco users ("Field Cancerization"). * **Nodal Staging:** A node >6 cm or any node with clinical fixation is generally staged as **N3**.
Question 38: A biopsy of a reasonably well-demarcated mass of the nasopharynx from a 30-year-old man demonstrates a plasma cell proliferation. Serum electrophoresis shows a small monoclonal IgG spike. Bone marrow evaluation fails to demonstrate plasma cell proliferation, and no lesions are seen on extensive skeletal x-rays. Which of the following is the most likely diagnosis?
- A. Heavy chain disease
- B. Monoclonal gammopathy of undetermined significance
- C. Multiple myeloma
- D. Plasmacytoma (Correct Answer)
Explanation: **Explanation:** The clinical presentation describes an **Extramedullary Plasmacytoma (EMP)**. This is a localized proliferation of neoplastic plasma cells occurring outside the bone marrow, most commonly in the upper respiratory tract (80% of cases occur in the head and neck, with the nasopharynx and paranasal sinuses being prime sites). **Why Plasmacytoma is correct:** The diagnosis is confirmed by the presence of a localized plasma cell mass in the nasopharynx combined with the **absence** of systemic features of Multiple Myeloma (normal bone marrow, no lytic bone lesions, and no CRAB features—Calcium elevation, Renal failure, Anemia, or Bone lesions). While a small monoclonal (M) protein spike can be seen in 25% of EMP cases, it does not automatically imply systemic disease. **Why other options are incorrect:** * **Multiple Myeloma:** Ruled out by the normal bone marrow biopsy and the absence of skeletal lytic lesions on X-ray. * **Monoclonal Gammopathy of Undetermined Significance (MGUS):** MGUS is characterized by an asymptomatic M-protein spike (<3g/dL) without a localized tumor mass or end-organ damage. This patient has a physical mass (plasmacytoma). * **Heavy Chain Disease:** This is a rare B-cell lymphoproliferative disorder characterized by the production of truncated heavy chains without light chains; it does not typically present as a localized nasopharyngeal mass. **NEET-PG High-Yield Pearls:** * **Treatment of Choice:** Radiotherapy (EMP is highly radiosensitive). * **Progression:** Unlike Solitary Plasmacytoma of Bone (SPB), Extramedullary Plasmacytoma (EMP) has a lower rate of conversion to Multiple Myeloma (approx. 15%). * **Most common site in Head & Neck:** Nasopharynx and Paranasal sinuses. * **Diagnostic Criteria:** Tissue biopsy showing plasma cells, <10% plasma cells in bone marrow, and negative skeletal survey.
Question 39: Commonest cancer of the oral cavity is?
- A. Adenocarcinoma
- B. Melanoma
- C. Sarcoma
- D. Squamous cell carcinoma (Correct Answer)
Explanation: **Explanation:** **Squamous Cell Carcinoma (SCC)** is the correct answer because it accounts for more than **90-95%** of all primary malignancies of the oral cavity. The oral cavity is lined by stratified squamous epithelium; chronic exposure to carcinogens (primarily tobacco, betel nut, and alcohol) leads to a progression from dysplasia to invasive carcinoma. In the Indian context, the **buccal mucosa** is the most common site for SCC due to the habit of keeping tobacco/betel quid in the cheek (often called the "Indian Oral Cancer"). **Analysis of Incorrect Options:** * **Adenocarcinoma:** These arise from the minor salivary glands located within the oral mucosa. While they are the second most common group of epithelial tumors, they are significantly rarer than SCC. * **Melanoma:** Mucosal melanomas are rare, highly aggressive tumors representing less than 1% of oral malignancies. They typically present as pigmented lesions on the hard palate or maxillary gingiva. * **Sarcoma:** These are non-epithelial tumors arising from mesenchymal tissues (bone, cartilage, or fat). They are extremely rare in the oral cavity compared to epithelial cancers. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site (Worldwide):** Lateral border of the tongue. * **Most common site (India):** Buccal mucosa (Gingivobuccal complex). * **Premalignant conditions:** Leukoplakia (most common), Erythroplakia (highest risk of transformation), and Oral Submucous Fibrosis (OSMF). * **Lymphatic Spread:** Usually spreads to Level I, II, and III neck nodes. * **Field Cancerization:** This concept explains why patients with one oral SCC are at high risk for developing synchronous or metachronous primary tumors in the upper aerodigestive tract.
Question 40: A 55-year-old chronic smoker presents with complaints of hoarseness of voice and a single enlarged painless lymph node in the left supraclavicular region. What is the next step in management?
- A. CT scan of the chest
- B. Sputum examination for AFB
- C. Laryngoscopy and chest X-ray
- D. Excision biopsy of the lymph node (Correct Answer)
Explanation: ### Explanation The correct answer is **D. Excision biopsy of the lymph node.** **1. Why Excision Biopsy is the Correct Step:** In a chronic smoker presenting with hoarseness and a supraclavicular lymph node (Virchow’s node), the primary concern is a metastatic malignancy. While hoarseness often suggests laryngeal cancer, a left supraclavicular node (Troisier’s sign) is classically associated with infra-diaphragmatic malignancies (e.g., gastric, esophageal) or lung cancer. In ENT oncology, the standard protocol for an isolated neck mass is usually FNAC. However, for **supraclavicular nodes**, if the primary site is not immediately obvious or if the node is suspicious for lymphoma or specific metastatic patterns, an **excision biopsy** is often required to provide definitive tissue architecture for histopathology and immunohistochemistry (IHC) to locate the primary tumor. **2. Why Other Options are Incorrect:** * **A. CT scan of the chest:** While useful for staging, it is not the immediate diagnostic step for a palpable metastatic node. Tissue diagnosis must precede extensive imaging. * **B. Sputum examination for AFB:** This is used to rule out Tuberculosis. While TB can cause lymphadenopathy, the patient’s age and smoking history make malignancy the much higher priority. * **C. Laryngoscopy and chest X-ray:** Laryngoscopy would evaluate the hoarseness (vocal cord palsy), but it does not provide a tissue diagnosis of the palpable supraclavicular mass, which is the most accessible site for biopsy. **3. Clinical Pearls for NEET-PG:** * **Troisier’s Sign:** The presence of a palpable left supraclavicular node (Virchow’s node), indicating metastatic spread from an abdominal or thoracic visceral malignancy via the thoracic duct. * **Hoarseness + Supraclavicular Node:** In a smoker, this combination strongly suggests **Lung Carcinoma** (involving the recurrent laryngeal nerve) or **Esophageal Carcinoma**. * **Rule of 80 in Neck Masses:** 80% of non-thyroid neck lumps in adults are neoplastic; 80% of those are malignant; 80% of those are metastatic. * **Golden Rule:** Never perform an open biopsy of a neck mass in Level I-IV until a primary in the upper aerodigestive tract is ruled out; however, supraclavicular nodes (Level V/VI) are exceptions where biopsy is often the diagnostic gateway.
Practice by Chapter
Staging of Head and Neck Cancer
Practice Questions
Oral Cavity Cancer
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Oropharyngeal Cancer and HPV
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Laryngeal Cancer
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Hypopharyngeal Cancer
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Sinonasal Malignancies
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Salivary Gland Neoplasms
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Thyroid Cancer
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Paragangliomas
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Principles of Radiation Therapy
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Chemotherapy and Targeted Therapy
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Surveillance and Survivorship
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