ENT Oncology — MCQs

A 55-year-old male patient complains of an abnormal growth on his right cheek. The patient has a history of tobacco chewing for 30 years. Radiologic findings reveal an 8x8 cm fungating mass invading the maxilla and mandible on the right side. Histologic findings are suggestive of squamous cell carcinoma. Which of the following statements regarding the treatment of this condition is NOT true?

Q59Medium

What is the treatment of choice for Carcinoma of the maxillary sinus with T3N0M0?

Q60Easy

Which of the following are predisposing factors for the development of oral carcinoma?

ENT Oncology Indian Medical PG Practice Questions and MCQs

Question 51: A patient with nasopharyngeal carcinoma can present with the following, except?

A. Horner's syndrome
B. Epistaxis and proptosis
C. Trismus
D. Sensorineural hearing loss (Correct Answer)

Explanation: **Explanation:** Nasopharyngeal Carcinoma (NPC) typically presents with a variety of symptoms due to its proximity to the skull base and Eustachian tube. **Why Sensorineural Hearing Loss (SNHL) is the correct answer:** NPC most commonly causes **Conductive Hearing Loss**, not SNHL. The tumor often originates in the Fossa of Rosenmüller, leading to the obstruction of the Eustachian tube orifice. This results in negative middle ear pressure and **Otitis Media with Effusion (OME)**. In an adult, unilateral serous otitis media is considered NPC until proven otherwise. **Analysis of Incorrect Options:** * **Horner’s Syndrome:** This occurs due to the involvement of the cervical sympathetic chain, typically when the tumor spreads to the parapharyngeal space or involves the apical lymph nodes (Level II/III). * **Epistaxis and Proptosis:** NPC is highly vascular; hence, epistaxis is a common early sign. Proptosis occurs when the tumor invades the orbit through the superior orbital fissure or the ethmoid sinuses. * **Trismus:** This indicates advanced local spread. It occurs due to the infiltration of the **pterygoid muscles** or involvement of the mandibular nerve (V3). **NEET-PG High-Yield Pearls:** 1. **Trotter’s Triad:** A classic diagnostic triad for NPC consisting of: * Conductive hearing loss (Eustachian tube blockage) * Ipsilateral palatal paralysis (Levator veli palatini involvement) * Trigeminal neuralgia/Facial pain (V nerve involvement) 2. **Etiology:** Strongly associated with **Epstein-Barr Virus (EBV)**. 3. **Most common symptom:** The most common presenting feature is actually a **painless cervical lymphadenopathy** (Upper deep cervical nodes). 4. **Treatment of Choice:** Radiotherapy is the primary treatment for NPC as it is highly radiosensitive.

Question 52: What is the appropriate treatment for squamous cell carcinoma of the maxilla with T3N0M0 staging?

A. Radiotherapy
B. Maxillectomy
C. Radiotherapy and maxillectomy (Correct Answer)
D. Maxillectomy and chemotherapy

Explanation: **Explanation:** The management of Squamous Cell Carcinoma (SCC) of the maxillary sinus depends heavily on the clinical stage. For **T3 and T4 lesions** (advanced local disease), the standard of care is **multimodal therapy**, typically involving surgical resection followed by adjuvant radiotherapy. 1. **Why Option C is Correct:** T3 staging indicates a large tumor (e.g., involving the posterior wall of the maxillary sinus, subcutaneous tissues, or floor of the orbit). Single-modality treatment (surgery or radiation alone) is associated with high recurrence rates in advanced stages. **Total Maxillectomy** followed by **Post-operative Radiotherapy (PORT)** provides the best local control and survival outcomes by addressing both the bulk of the tumor and microscopic residual disease. 2. **Why Other Options are Incorrect:** * **Option A (Radiotherapy alone):** Used only for T1/T2 lesions in patients unfit for surgery or for palliative care. It is insufficient for T3 tumors due to the radioresistant nature of bone involvement. * **Option B (Maxillectomy alone):** While surgery is the mainstay, T3 tumors have a high risk of positive margins and perineural invasion; surgery without adjuvant radiation leads to poor prognosis. * **Option D (Maxillectomy and chemotherapy):** While Chemoradiotherapy is used for T4b (unresectable) cases, the standard adjuvant treatment after surgery for T3N0 is Radiotherapy. Chemotherapy is usually reserved for cases with positive margins or extracapsular spread. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Maxillary sinus is the most common site for paranasal sinus tumors. * **Most common histology:** Squamous Cell Carcinoma. * **Ohngren’s Line:** An imaginary line connecting the medial canthus to the angle of the mandible. Tumors **posterosuperior** to this line have a poorer prognosis. * **Lymphatic Spread:** Rare in early stages (N0 is common) because the maxillary sinus has sparse lymphatics. * **Staging Tip:** T3 involves the posterior wall, floor/medial wall of the orbit, or ethmoid sinus. T4a involves the anterior orbit, skin of the cheek, or pterygoid plates.

Question 53: Which anatomical region is primarily involved in Nasopharyngeal Carcinoma?

A. Nasopharyngeal cavity (Correct Answer)
B. Oropharynx
C. Oral cavity
D. All of the above

Explanation: **Explanation:** **Nasopharyngeal Carcinoma (NPC)** is a unique epithelial malignancy that arises from the mucosal lining of the nasopharynx. The correct answer is **Nasopharyngeal cavity** because the tumor specifically originates from the epithelium of the nasopharynx, most commonly from the **Fossa of Rosenmüller** (the pharyngeal recess located posterior to the medial end of the Eustachian tube). **Why other options are incorrect:** * **Oropharynx:** This region (including the base of tongue and tonsils) is the site for Oropharyngeal Squamous Cell Carcinoma, which is etiologically linked to HPV-16, whereas NPC is strongly associated with the **Epstein-Barr Virus (EBV)**. * **Oral cavity:** This includes the lips, buccal mucosa, and anterior tongue. Malignancies here are typically associated with tobacco and betel nut chewing, distinct from the genetic and viral drivers of NPC. **Clinical Pearls for NEET-PG:** * **Most Common Site:** Fossa of Rosenmüller. * **Etiology:** Strong association with **EBV** (Type II and III WHO classification) and dietary factors like salted fish (nitrosamines). * **Clinical Presentation:** The classic triad includes a **neck mass** (most common presenting symptom, usually level II/V nodes), **nasal obstruction/epistaxis**, and **otological symptoms** (unilateral serous otitis media due to Eustachian tube blockage). * **Trotter’s Triad:** Conductive deafness, ipsilateral temporofacial neuralgia (CN V involvement), and palatal paralysis (CN X involvement). * **Treatment of Choice:** Radiotherapy (NPC is highly radiosensitive).

Question 54: What is true about the AJCC staging of oral cavity carcinoma?

A. Involvement of the pterygoid plate is stage T3.
B. Involvement of the pterygoid plate is stage T4.
C. Involvement of the lateral pterygoid muscle is stage T4.
D. Involvement of the medial pterygoid muscle is stage T3. (Correct Answer)

Explanation: The AJCC 8th Edition updated the staging for oral cavity carcinoma to better reflect prognostic outcomes, specifically regarding the depth of invasion (DOI) and anatomical structures involved. ### **Explanation of the Correct Option** **D. Involvement of the medial pterygoid muscle is stage T3.** In the AJCC 8th edition, the involvement of the **medial pterygoid muscle** or the **cortical bone of the mandible/maxilla** is no longer considered an automatic T4a (moderately advanced) disease. Instead, if the tumor is >4 cm or has a DOI >10 mm, or involves these specific structures without further extension, it is classified as **T3**. This change was made because involvement of the medial pterygoid alone does not carry the same poor prognosis as involvement of the deeper masticator space. ### **Why Other Options are Incorrect** * **A & B: Involvement of the pterygoid plate.** Involvement of the **pterygoid plates** (medial or lateral) signifies advanced disease that has reached the skull base region. This is classified as **T4b** (very advanced local disease). * **C: Involvement of the lateral pterygoid muscle.** While the medial pterygoid is T3, involvement of the **lateral pterygoid muscle**, the pterygoid plates, or the nasopharynx is classified as **T4b**. ### **High-Yield Clinical Pearls for NEET-PG** * **DOI vs. Thickness:** Staging now relies on **Depth of Invasion (DOI)**, not tumor thickness. DOI is measured from the level of the adjacent normal mucosa. * **T1:** $\leq$ 2 cm AND DOI $\leq$ 5 mm. * **T2:** $\leq$ 2 cm with DOI 5–10 mm OR 2–4 cm with DOI $\leq$ 10 mm. * **T3:** > 4 cm OR DOI > 10 mm OR involvement of medial pterygoid/cortical bone. * **T4a:** Invades through cortical bone into deep/extrinsic muscles of the tongue, maxillary sinus, or skin of the face. * **T4b:** Invades masticator space (lateral pterygoid), pterygoid plates, or skull base.

Question 55: What is the T stage for carcinoma of the epiglottis involving the pre-epiglottic space?

A. T3 stage (Correct Answer)
B. T2 stage
C. T1 stage
D. T4 stage

Explanation: **Explanation:** The staging of Supraglottic Laryngeal Carcinoma (which includes the epiglottis) is determined by the extent of local invasion and vocal cord mobility. **Why T3 is the correct answer:** According to the AJCC (8th Edition) TNM staging for the supraglottis, a tumor is classified as **T3** if it is limited to the larynx but involves any of the following: 1. **Invasion of the pre-epiglottic space.** 2. Invasion of the paraglottic space. 3. Fixation of the vocal cords. 4. Inner cortex of the thyroid cartilage invasion. The pre-epiglottic space is a fat-filled potential space located anterior to the epiglottis; its involvement signifies deeper infiltration, upgrading the stage to T3. **Why other options are incorrect:** * **T1:** The tumor is limited to one subsite of the supraglottis (e.g., lingual surface of the epiglottis) with normal vocal cord mobility. * **T2:** The tumor invades more than one adjacent subsite of the supraglottis or glottis, or a region outside the supraglottis (e.g., mucosa of the base of tongue), without fixation of the larynx. * **T4:** This represents advanced disease. **T4a** involves invasion through the outer cortex of the thyroid cartilage or into soft tissues of the neck (thyroid, esophagus). **T4b** involves the prevertebral space or encasement of the carotid artery. **High-Yield Clinical Pearls for NEET-PG:** * **Pre-epiglottic space:** Bound by the hyoid bone (superiorly), thyroid cartilage/thyrohyoid membrane (anteriorly), and epiglottis (posteriorly). * **Hyo-epiglottic ligament:** Forms the "roof" of the pre-epiglottic space. * **Most common site** of Supraglottic CA: Epiglottis. * **Lymphatic spread:** Supraglottic tumors have a rich lymphatic network; hence, bilateral neck node involvement is common compared to glottic tumors.

Question 56: Nasopharyngeal carcinoma does not involve which of the following structures?

A. Nasal cavity
B. Oropharynx
C. Pyriform fossa (Correct Answer)
D. Orbit

Explanation: **Explanation:** Nasopharyngeal carcinoma (NPC) most commonly arises from the **Fossa of Rosenmüller**. Its spread is characterized by local infiltration along planes of least resistance and early lymphatic metastasis. **1. Why Pyriform Fossa is the Correct Answer:** The pyriform fossa is a part of the **hypopharynx**, located significantly inferior to the nasopharynx. NPC spreads via direct extension to adjacent structures or via the retropharyngeal and cervical lymph nodes. It does not typically skip the oropharynx and larynx to involve the hypopharynx (pyriform fossa) through direct local spread. Therefore, it is the least likely structure to be involved in the primary disease process. **2. Analysis of Incorrect Options:** * **Nasal Cavity:** NPC frequently spreads **anteriorly** through the choanae to involve the posterior nasal cavity, causing symptoms like nasal obstruction and epistaxis. * **Oropharynx:** NPC spreads **inferiorly** along the pharyngeal walls to involve the soft palate and the oropharynx. * **Orbit:** NPC can spread **superiorly** through the skull base (foramen lacerum or superior orbital fissure) or via the ethmoid sinuses to enter the orbit, leading to proptosis or ophthalmoplegia. **Clinical Pearls for NEET-PG:** * **Most common histological type:** Undifferentiated carcinoma (WHO Type III), strongly associated with **Epstein-Barr Virus (EBV)**. * **Trotter’s Triad:** Conductive deafness (Eustachian tube blockage), Palatal paralysis (CN X involvement), and Temporofacial neuralgia (CN V involvement). * **Nodal Spread:** The **Node of Rouviere** (lateral retropharyngeal node) is often the first to be involved. * **Treatment of Choice:** Radiotherapy is the primary treatment for both the primary tumor and the neck.

Question 57: Which one of the following is the most common tumor to produce metastasis to cervical lymph nodes?

A. Glottic carcinoma
B. Nasopharyngeal carcinoma (Correct Answer)
C. Carcinoma base of tongue
D. Carcinoma lip

Explanation: **Explanation:** The correct answer is **Nasopharyngeal Carcinoma (NPC)**. This is due to the rich lymphatic network of the nasopharynx and the aggressive biological nature of the tumor. **Why Nasopharyngeal Carcinoma is correct:** NPC is notorious for early and frequent lymphatic spread. Approximately **75-90% of patients** present with a cervical neck mass as their first clinical symptom. The primary drainage is to the **Node of Rouviere** (lateral retropharyngeal node) and Level II/III nodes. It is also the most common head and neck cancer to present with **bilateral** cervical lymphadenopathy. **Analysis of Incorrect Options:** * **Glottic Carcinoma:** The true vocal cords have **virtually no lymphatic drainage**. Therefore, glottic cancer rarely metastasizes to the neck in early stages (T1/T2), making it the least likely among the options to produce metastasis. * **Carcinoma Base of Tongue:** While this has a high rate of metastasis (approx. 70-80%) due to its rich midline-crossing lymphatics, NPC still ranks higher in terms of frequency of nodal presentation as the *initial* sign. * **Carcinoma Lip:** This typically has a low rate of metastasis (approx. 5-10%), usually involving the submental or submandibular nodes (Level I) only in advanced stages. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of NPC:** Fossa of Rosenmüller. * **Trotter’s Triad (NPC):** Conductive hearing loss (serous otitis media), palatal palsy, and trigeminal neuralgia. * **EBV Association:** NPC (especially Type 2 and 3) is strongly associated with Epstein-Barr Virus. * **Nodal Level:** NPC is a classic cause of Level V (posterior triangle) lymphadenopathy.

Question 58: A 55-year-old male patient complains of an abnormal growth on his right cheek. The patient has a history of tobacco chewing for 30 years. Radiologic findings reveal an 8x8 cm fungating mass invading the maxilla and mandible on the right side. Histologic findings are suggestive of squamous cell carcinoma. Which of the following statements regarding the treatment of this condition is NOT true?

A. The drugs used are designed to block DNA replication.
B. Methotrexate and 5-fluorouracil block nucleotide synthesis.
C. Topoisomerase inhibitors promote the unwinding of parental DNA strands and prevent replication. (Correct Answer)
D. The drugs used for cancer therapy inhibit the enzymes that participate in replication.

Explanation: ### Explanation The question focuses on the mechanism of action of chemotherapeutic agents used in Head and Neck Squamous Cell Carcinoma (HNSCC). **Why Option C is the Correct Answer (The False Statement):** Topoisomerase inhibitors (e.g., Etoposide, Irinotecan) do **not** promote the unwinding of DNA. In fact, DNA unwinding is naturally performed by the enzyme **Helicase**. Topoisomerases are responsible for relieving the torsional strain (supercoiling) created during unwinding by inducing single or double-stranded breaks. Topoisomerase inhibitors work by "trapping" the enzyme-DNA complex, preventing the re-ligation of these strands. This leads to permanent DNA breaks and apoptosis, rather than facilitating unwinding. **Analysis of Incorrect Options (True Statements):** * **Option A:** Most conventional chemotherapeutic agents (Antimetabolites, Alkylating agents) are specifically designed to disrupt the S-phase of the cell cycle by blocking DNA replication. * **Option B:** Methotrexate (a folate antagonist) and 5-Fluorouracil (a pyrimidine analog) are classic antimetabolites that inhibit enzymes like dihydrofolate reductase and thymidylate synthase, respectively, thereby blocking the synthesis of nucleotides required for DNA. * **Option C:** Many anticancer drugs function by inhibiting specific enzymes involved in replication, such as DNA polymerase, ribonucleotide reductase, or topoisomerases. **Clinical Pearls for NEET-PG:** * **Risk Factors:** Tobacco chewing is the strongest risk factor for oral cavity SCC in India (often presenting as the "Indian Buccal Sulcus" cancer). * **Drug of Choice:** Cisplatin is the most commonly used radiosensitizer in locally advanced HNSCC. * **Topoisomerase I Inhibitors:** Irinotecan, Topotecan. * **Topoisomerase II Inhibitors:** Etoposide, Teniposide, Doxorubicin. * **Helicase:** The actual enzyme responsible for ATP-dependent unwinding of the DNA double helix.

Question 59: What is the treatment of choice for Carcinoma of the maxillary sinus with T3N0M0?

A. Surgery
B. Radiotherapy
C. Surgery and Radiotherapy (Correct Answer)
D. Surgery and chemotherapy

Explanation: **Explanation:** **1. Why Option C is Correct:** Carcinoma of the maxillary sinus (most commonly Squamous Cell Carcinoma) is often diagnosed at an advanced stage due to its silent early progression. For **T3 and T4 tumors** (locally advanced disease), the standard of care is **multimodal therapy**. * **Surgery:** Usually involves a Total Maxillectomy to achieve local control. * **Radiotherapy:** Post-operative radiotherapy (PORT) is essential because these tumors often have close or positive margins due to the complex anatomy of the skull base and orbit. Combining surgery with radiation significantly improves local control and survival rates compared to either modality alone. **2. Why Other Options are Incorrect:** * **Option A (Surgery alone):** While surgery is the primary treatment, using it alone for a T3 lesion carries a very high risk of local recurrence. * **Option B (Radiotherapy alone):** Maxillary sinus tumors are relatively radioresistant. Radiotherapy alone is generally reserved for palliative cases or patients who are medically unfit for surgery. * **Option D (Surgery and Chemotherapy):** While chemotherapy (specifically Cisplatin) may be added to radiotherapy (chemoradiation) for T4 tumors or positive margins, the core "treatment of choice" for T3 remains the combination of Surgery and Radiotherapy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common histology:** Squamous Cell Carcinoma (80%). * **Most common site:** The maxillary sinus is the most common site for paranasal sinus malignancies. * **Ohngren’s Line:** An imaginary line connecting the medial canthus to the angle of the mandible. Tumors **posterosuperior** to this line have a poorer prognosis. * **Lymphatic Spread:** N0 is common because the maxillary sinus has sparse lymphatics; however, if the tumor invades the cheek or palate, submandibular nodes (Level II) become involved. * **Lederman’s Classification:** Uses two horizontal lines (passing through the floor of the orbit and floor of the antrum) to divide the area into suprastructure, mesostructure, and infrastructure.

Question 60: Which of the following are predisposing factors for the development of oral carcinoma?

A. Smoking
B. Alcohol
C. Syphilis
D. All of the above (Correct Answer)

Explanation: Oral carcinoma is a multifactorial disease primarily driven by chronic mucosal irritation and DNA damage. The correct answer is **All of the above** because smoking, alcohol, and syphilis are all established independent and synergistic risk factors. ### **Explanation of Factors:** 1. **Smoking (Tobacco):** This is the most significant risk factor. Tobacco contains potent carcinogens like nitrosamines and polycyclic aromatic hydrocarbons. These cause direct DNA mutations in the squamous epithelium. When combined with alcohol, the risk increases synergistically (the "multiplier effect"). 2. **Alcohol:** While not a direct mutagen, alcohol acts as a solvent, increasing the permeability of the oral mucosa to other carcinogens (like tobacco). Its metabolite, acetaldehyde, also interferes with DNA repair mechanisms. 3. **Syphilis:** Historically, tertiary syphilis is associated with **"Luetic Glossitis."** Chronic inflammation leads to atrophy of the lingual papillae (atrophic glossitis), creating a "bald tongue" that is highly susceptible to malignant transformation, typically on the dorsum of the tongue. ### **Why other options are not "wrong":** In a "Multiple Choice" format where all listed factors contribute to the pathology, the "All of the above" option is the most accurate representation of the disease's etiology. ### **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** In India, it is the **buccal mucosa** (due to betel nut/tobacco chewing—the "Indian oral habit"). Globally, it is the lateral border of the tongue. * **Premalignant Lesions:** Erythroplakia (highest risk of transformation), Leukoplakia, and Oral Submucous Fibrosis (OSMF). * **Plummer-Vinson Syndrome:** Associated with post-cricoid carcinoma and oral cavity cancers due to iron deficiency causing mucosal atrophy. * **Field Cancerization:** A concept where the entire exposure area (oral cavity/pharynx) is at risk of developing multiple primary tumors due to widespread carcinogen exposure.

Practice by Chapter

Staging of Head and Neck Cancer

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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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