ENT Oncology Practice Questions

Q: What is the most common and earliest manifestation of carcinoma of the glottis?

Hoarseness. **Explanation:** **Why Hoarseness is the Correct Answer:** Carcinoma of the glottis (vocal cords) is the most common site for laryngeal cancer. **Hoarseness of voice** is both the **earliest and the most common** symptom [2]. This occurs because even a tiny lesion on the free edge of the vocal cord interferes with its vibratory pattern and prevents complete approximation during phonation. Because the glottis has a very sparse lymphatic network, these tumors tend to remain localized for a long time, making hoarseness a critical early warning sign that often leads to early diagnosis and a high cure rate. **Why Other Options are Incorrect:** * **B. Hemoptysis:** This is usually a late feature occurring due to surface ulceration and necrosis of the tumor. * **C. Cervical lymph nodes:** Glottic cancers rarely present with lymphadenopathy early because the true vocal cords have **no lymphatic drainage** (Level II/III nodes are involved only if the tumor spreads to supraglottic or subglottic regions). * **D. Stridor:** This is a sign of significant airway obstruction and indicates an advanced, late-stage tumor [2]. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Laryngeal CA:** Glottis (60%), followed by Supraglottis (35%). * **Best Prognosis:** Glottic CA (due to early symptoms and poor lymphatics). * **Worst Prognosis:** Subglottic CA (clinically silent until late stages). * **Rule of Thumb:** Any patient with hoarseness persisting for more than **3 weeks** must undergo a direct or indirect laryngoscopy to rule out malignancy [1].

Q: Which is the best prognosticator of survival from nasopharyngeal carcinoma?

WHO type III histology. **Explanation:** The prognosis of Nasopharyngeal Carcinoma (NPC) is heavily influenced by its histopathological subtype and its sensitivity to treatment. **Why WHO Type III is the correct answer:** The WHO classification divides NPC into three types: * **Type I:** Keratinizing squamous cell carcinoma. * **Type II:** Non-keratinizing differentiated carcinoma. * **Type III:** Undifferentiated carcinoma (including lymphoepithelioma). **WHO Type III** is the most common subtype and, despite its aggressive appearance, it has the **best prognosis**. This is because Type III tumors are highly **radiosensitive** and **chemosensitive**. They are also strongly associated with the Epstein-Barr Virus (EBV) and occur in younger age groups compared to Type I. **Analysis of Incorrect Options:** * **Option A (High angiogenesis):** While increased vascularity often correlates with tumor growth and potential for spread, it is a general pathological feature and not the primary prognosticator used in clinical practice for NPC. * **Option C (Lung metastases):** Distant metastasis (M1 stage) is a sign of advanced disease and indicates a **poor prognosis**, not the "best" prognosticator for survival. * **Option D (WHO Type I):** This subtype has the **worst prognosis**. It is least sensitive to radiotherapy, has a lower association with EBV, and is more common in older patients with a history of smoking/alcohol. **NEET-PG High-Yield Pearls:** * **Most common site:** Fossa of Rosenmüller. * **Most common symptom:** Painless upper deep cervical lymphadenopathy. * **Most common cranial nerve involved:** 6th CN (Abducens), leading to diplopia. * **Trotter’s Triad:** Conductive hearing loss (serous otitis media), palatal paralysis, and temporofacial neuralgia (5th CN involvement). * **Treatment of choice:** Radiotherapy (RT) is the primary modality; Chemoradiotherapy (CRT) for advanced stages. Surgery is reserved for salvage.

Q: Involvement of neck lymph nodes is seen in all the following conditions except?

Vocal cord carcinoma. The correct answer is **Vocal cord carcinoma** because of the unique lymphatic anatomy of the larynx. ### **1. Why Vocal Cord Carcinoma is the Correct Answer** The true vocal cords (glottis) are characterized by a **paucity of lymphatic drainage**. The epithelium is tightly bound to the underlying Reinke’s space, which lacks a well-developed lymphatic network. Consequently, early-stage glottic cancer (T1/T2) rarely metastasizes to the neck lymph nodes (incidence <1-2%). This is a high-yield clinical fact: patients with vocal cord cancer usually present early with hoarseness and have an excellent prognosis because the disease remains localized for a long duration. ### **2. Why the Other Options are Incorrect** * **Hodgkin’s Lymphoma:** Cervical lymphadenopathy is the most common presenting feature (seen in ~60-80% of cases). The nodes are typically firm, rubbery, and painless. * **Tumors of the Hypopharynx:** The hypopharynx has an extremely rich lymphatic network. Over 50-70% of patients present with palpable neck nodes (Level II, III, and IV) at the time of diagnosis. * **Nasopharyngeal Carcinoma:** This tumor is notorious for early lymphatic spread. In many cases, a neck mass (Level II or V) is the first clinical sign (Trottier’s triad). It has the highest incidence of bilateral nodal involvement among head and neck cancers. ### **3. NEET-PG High-Yield Pearls** * **Laryngeal Lymphatics:** The **Supraglottis** has the richest lymphatic drainage (Level II/III), while the **Glottis** has the least. * **Level of Nodes:** Nasopharyngeal carcinoma typically involves **Level V** (Posterior triangle) and **Level II** (Upper jugular) nodes. * **Most common site** for unknown primary presenting as a neck node: Palatine tonsil, Base of tongue, or Nasopharynx.

Q: Fisch classification is used for which type of tumor?

Glomus tumors. **Explanation:** The **Fisch Classification** is the gold standard for staging **Glomus tumors** (Paragangliomas) of the temporal bone, specifically Glomus Tympanicum and Glomus Jugulare. This classification is crucial for surgical planning as it categorizes tumors based on their anatomical extension and involvement of the skull base. * **Type A:** Tumors restricted to the middle ear cleft (Glomus Tympanicum). * **Type B:** Tumors confined to the tympanomastoid area without bone destruction of the infralabyrinthine compartment. * **Type C:** Tumors extending into the infralabyrinthine compartment and involving the carotid canal. * **Type D:** Tumors with intracranial extension. **Analysis of Incorrect Options:** * **Paravertebral and Retroperitoneal tumors:** These are typically staged using the TNM system or specific sarcoma staging (like Enneking for bone/soft tissue). * **Synovial sarcomas:** These are soft tissue sarcomas staged primarily by size, grade, and nodal involvement (AJCC staging), not by the Fisch system. **High-Yield Clinical Pearls for NEET-PG:** 1. **Glasscock-Jackson Classification** is the other major system used for Glomus tumors; however, Fisch is more commonly tested regarding skull base involvement. 2. **Pulsatile Tinnitus** and a **"Rising Sun" appearance** (red vascular mass behind the tympanic membrane) are classic clinical presentations. 3. **Brown’s Sign:** Positive when the mass blanches on applying pressure with a Siegel’s speculum. 4. **Aquino’s Sign:** Pulsations of the tumor decrease or disappear on carotid artery compression.

Q: Horner's syndrome is caused by:

Nasopharyngeal carcinoma with metastasis. **Explanation:** **1. Why Option B is Correct:** Horner’s syndrome results from a disruption of the **sympathetic nerve supply** to the eye. In the context of ENT oncology, **Nasopharyngeal Carcinoma (NPC)** can cause this syndrome through two primary mechanisms: * **Direct Extension:** The tumor can invade the parapharyngeal space, involving the cervical sympathetic chain. * **Metastasis:** NPC frequently metastasizes to the **retropharyngeal lymph nodes (Nodes of Rouviere)** or the deep cervical nodes. Enlargement of these nodes can compress the sympathetic chain at the level of the carotid sheath, leading to the classic triad of miosis, partial ptosis, and anhidrosis. **2. Why Other Options are Incorrect:** * **Facial Injury (A):** While trauma can cause Horner’s syndrome, it must specifically involve the neck or thoracic outlet (brachial plexus). A general facial injury typically affects the facial nerve (CN VII), leading to facial palsy, not sympathetic chain disruption. * **Meniere’s Disease (C):** This is an inner ear disorder characterized by endolymphatic hydrops. It presents with vertigo, tinnitus, and sensorineural hearing loss; it has no anatomical or physiological link to the sympathetic nervous system. **3. High-Yield Clinical Pearls for NEET-PG:** * **Trotter’s Triad (NPC):** 1. Conductive deafness (Eustachian tube blockage), 2. Ipsilateral facial pain/numbness (CN V involvement), 3. Palatal paralysis (CN X involvement). * **Pancoast Tumor:** Another high-yield cause of Horner’s syndrome (apical lung carcinoma involving the stellate ganglion). * **Clinical Triad of Horner’s:** Miosis (constricted pupil), Partial Ptosis (Muller’s muscle paralysis), and Anhidrosis (loss of sweating). Enophthalmos is often an apparent, rather than true, finding.

Q: Which of the following is most commonly used for the treatment of early carcinoma of the vocal cord?

Radical radiotherapy. **Explanation:** The primary goal in treating early glottic carcinoma (Stage T1 and T2) is to achieve a high cure rate while **preserving laryngeal function and voice quality**. **1. Why Radical Radiotherapy is Correct:** Radical radiotherapy (RT) is the treatment of choice for early vocal cord cancer because it offers excellent local control rates (85-95% for T1) comparable to surgery, but with a **superior functional outcome**. It preserves the structural integrity of the vocal cords, resulting in a better post-treatment voice quality compared to most surgical interventions. **2. Why Other Options are Incorrect:** * **B. High-dose chemotherapy:** Chemotherapy is not used as a primary or standalone treatment for early-stage laryngeal cancer. It is typically reserved for advanced stages (T3, T4) as part of organ-preservation protocols (chemoradiation) or for palliative care. * **C. Total laryngectomy:** This is an aggressive, mutilating surgery reserved for advanced (T4) lesions where there is extensive cartilage destruction or extralaryngeal spread. It is "over-treatment" for early-stage disease. * **D. Hemilaryngectomy followed by chemotherapy:** While partial laryngectomy (like hemilaryngectomy) is a surgical alternative for T1 lesions, it is not routinely followed by chemotherapy. Furthermore, surgery often results in a breathy or hoarse voice compared to RT. **Clinical Pearls for NEET-PG:** * **T1a vs. T1b:** T1a involves one vocal cord; T1b involves both. RT is excellent for both. * **Surgery vs. RT:** If surgery is chosen for early lesions, **Transoral CO2 Laser Microsurgery (TLM)** is now preferred over open hemilaryngectomy due to faster recovery. * **Recurrence:** If RT fails, "salvage surgery" (partial or total laryngectomy) can still be performed. * **Voice Quality:** RT > Laser Surgery > Open Partial Surgery.

Q: What is the most common type of oral carcinoma?

Tongue. **Explanation:** In the context of oral cavity malignancies, **Squamous Cell Carcinoma (SCC)** is the most common histological type, accounting for over 90% of cases. Among the various anatomical sites within the oral cavity, the **Tongue** (specifically the lateral border and ventral surface of the anterior two-thirds) is the most common site for carcinoma worldwide. * **Why Tongue is Correct:** The tongue is highly susceptible due to its constant exposure to carcinogens (tobacco and alcohol) dissolved in saliva, which tends to pool in the floor of the mouth and contact the lateral borders. It also has a rich lymphatic drainage, leading to early nodal metastasis. * **Why others are incorrect:** * **Lip:** While common in Western countries due to solar radiation (specifically the lower lip), it is less frequent than tongue cancer in the Indian subcontinent. * **Cheek (Buccal Mucosa):** This is the most common site for oral cancer **specifically in India** due to the habit of "betel nut and tobacco chewing" (the tobacco bolus is kept in the buccal sulcus). However, globally and in general ENT textbooks (like Dhingra), the tongue remains the top answer unless "India" is specified. * **Palate:** Malignancies of the hard palate are relatively rare and are more frequently of minor salivary gland origin rather than SCC. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common site in India:** Buccal Mucosa (due to tobacco chewing). 2. **Most common site worldwide:** Tongue. 3. **Premalignant conditions:** Leukoplakia (most common) and Erythroplakia (highest risk of transformation). 4. **Nodal Spread:** Tongue cancers often spread to Level II (upper deep cervical) nodes. 5. **Field Cancerization:** This concept explains why patients with one oral primary are at high risk for synchronous or metachronous tumors.

Q: Which of the following statements about nasopharyngeal carcinoma is false?

Generally has a good prognosis. **Explanation:** Nasopharyngeal Carcinoma (NPC) is a unique head and neck cancer with distinct epidemiological and clinical characteristics. **Why Option C is False (The Correct Answer):** Nasopharyngeal carcinoma generally has a **poor prognosis**. This is due to several factors: the anatomical location makes surgical access difficult, the tumor is often clinically silent in early stages, and it has a high propensity for early lymphatic spread. Most patients present at an advanced stage (Stage III or IV), leading to lower overall survival rates compared to other head and neck cancers. **Analysis of Other Options:** * **Option A (Rhinolalia Clausa):** NPC originates in the nasopharynx (most commonly the Fossa of Rosenmüller). Large growths cause posterior nasal obstruction, leading to "hyponasality" or **rhinolalia clausa** (denasal speech). * **Option B (Radiotherapy):** Because NPC is highly radiosensitive and surgically inaccessible, **Radiotherapy is the primary treatment modality** for all stages. Chemotherapy is added for advanced stages (Concurrent Chemoradiotherapy). * **Option D (Horner’s Syndrome):** NPC is notorious for skull base invasion. Involvement of the **parapharyngeal space** can damage the cervical sympathetic chain, resulting in ipsilateral Horner’s syndrome (ptosis, miosis, anhidrosis). **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Strongly associated with **Epstein-Barr Virus (EBV)** and dietary nitrosamines (salted fish). * **Trotter’s Triad:** 1. Conductive hearing loss (Eustachian tube blockage), 2. Ipsilateral facial pain (Trigeminal nerve involvement), 3. Palatal palsy. * **Most Common Presentation:** Level II/Upper jugular **painless cervical lymphadenopathy**. * **WHO Classification:** Type 1 (Keratinizing), Type 2 (Non-keratinizing), Type 3 (Undifferentiated/Lymphoepithelioma). Type 3 is the most common and most radiosensitive.

Q: Tonsillar carcinoma is associated with infection of which virus?

Human Papillomavirus (HPV). **Explanation:** Tonsillar carcinoma is a subset of Oropharyngeal Squamous Cell Carcinoma (OPSCC). The correct answer is **Human Papillomavirus (HPV)**, specifically high-risk strains like **HPV-16** (found in over 90% of HPV-positive cases). **Why HPV is the correct answer:** HPV has a strong tropism for the reticulated epithelium of the palatine and lingual tonsils. The virus integrates into the host genome, leading to the overexpression of oncoproteins **E6 and E7**. E6 degrades the p53 tumor suppressor protein, while E7 inactivates the Retinoblastoma (Rb) protein, resulting in uncontrolled cell proliferation. **Why other options are incorrect:** * **HIV:** While HIV-infected individuals have a higher risk of various malignancies (like Kaposi sarcoma or Non-Hodgkin Lymphoma) due to immunosuppression, HIV is not the direct causative agent of tonsillar carcinoma. * **HSV:** Herpes Simplex Virus is primarily associated with mucocutaneous lesions (cold sores/genital herpes) and encephalitis, but it is not an oncogenic virus for oropharyngeal cancer. **High-Yield Clinical Pearls for NEET-PG:** 1. **Epidemiology:** HPV-positive tonsillar cancers typically occur in younger patients, often without the traditional risk factors of heavy smoking or alcohol use. 2. **Surrogate Marker:** **p16 immunohistochemistry** is used as a reliable surrogate marker for HPV infection in oropharyngeal biopsies. 3. **Prognosis:** HPV-positive oropharyngeal cancers generally have a **better prognosis** and higher sensitivity to radiotherapy/chemotherapy compared to HPV-negative (tobacco-related) cancers. 4. **Staging:** Due to the better prognosis, the AJCC 8th Edition has separate staging systems for HPV-mediated (p16+) oropharyngeal cancers.

Question 1

What is the most common and earliest manifestation of carcinoma of the glottis?

Accepted Answer

Hoarseness

Answer

Hemoptysis

Answer

Cervical lymph nodes

Answer

Stridor

Question 2

The prognosis for squamous cell carcinoma of the floor of the mouth is adversely affected by which of the following?

Accepted Answer

Poor differentiation of tumor

Answer

Nonverrucous carcinoma

Answer

Presence on the left side

Answer

No tongue involvement

Question 3

Which is the best prognosticator of survival from nasopharyngeal carcinoma?

Accepted Answer

WHO type III histology

Answer

High angiogenesis in the tumor

Answer

Lung metastases

Answer

WHO type I histology

Question 4

Involvement of neck lymph nodes is seen in all the following conditions except?

Accepted Answer

Vocal cord carcinoma

Answer

Hodgkin's lymphoma

Answer

Tumors of the hypopharynx

Answer

Nasopharyngeal carcinoma

Question 5

Fisch classification is used for which type of tumor?

Accepted Answer

Glomus tumors

Answer

Paravertebral tumors

Answer

Synovial sarcomas

Answer

Retroperitoneal tumors

Question 6

Horner's syndrome is caused by:

Accepted Answer

Nasopharyngeal carcinoma with metastasis

Answer

Facial injury

Answer

Meniere's disease

Answer

All of the above

Question 7

Which of the following is most commonly used for the treatment of early carcinoma of the vocal cord?

Accepted Answer

Radical radiotherapy

Answer

High-dose chemotherapy

Answer

Total laryngectomy

Answer

Hemilaryngectomy followed by chemotherapy

Question 8

What is the most common type of oral carcinoma?

Accepted Answer

Tongue

Answer

Lip

Answer

Cheek

Answer

Palate

Question 9

Which of the following statements about nasopharyngeal carcinoma is false?

Accepted Answer

Generally has a good prognosis

Answer

Associated with rhinolalia clausa

Answer

Radiotherapy is the main modality of treatment

Answer

Can present with Horner's syndrome

Question 10

Tonsillar carcinoma is associated with infection of which virus?

Accepted Answer

Human Papillomavirus (HPV)

Answer

Human Immunodeficiency Virus (HIV)

Answer

Herpes Simplex Virus (HSV)

Answer

None of the above

ENT Oncology — MCQs

ENT Oncology — MCQs

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