ENT Oncology Practice Questions

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

Sensorineural hearing loss. **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.

Q: Which anatomical region is primarily involved in Nasopharyngeal Carcinoma?

Nasopharyngeal cavity. **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).

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

Involvement of the medial pterygoid muscle is stage T3.. 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.

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

T3 stage. **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.

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

Pyriform fossa. **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.

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

Nasopharyngeal carcinoma. **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 1

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

Accepted Answer

Sensorineural hearing loss

Answer

Horner's syndrome

Answer

Epistaxis and proptosis

Answer

Trismus

Question 2

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

Accepted Answer

Radiotherapy and maxillectomy

Answer

Radiotherapy

Answer

Maxillectomy

Answer

Maxillectomy and chemotherapy

Question 3

Which anatomical region is primarily involved in Nasopharyngeal Carcinoma?

Accepted Answer

Nasopharyngeal cavity

Answer

Oropharynx

Answer

Oral cavity

Answer

All of the above

Question 4

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

Accepted Answer

Involvement of the medial pterygoid muscle is stage T3.

Answer

Involvement of the pterygoid plate is stage T3.

Answer

Involvement of the pterygoid plate is stage T4.

Answer

Involvement of the lateral pterygoid muscle is stage T4.

Question 5

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

Accepted Answer

T3 stage

Answer

T2 stage

Answer

T1 stage

Answer

T4 stage

Question 6

Nasopharyngeal carcinoma does not involve which of the following structures?

Accepted Answer

Pyriform fossa

Answer

Nasal cavity

Answer

Oropharynx

Answer

Orbit

Question 7

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

Accepted Answer

Nasopharyngeal carcinoma

Answer

Glottic carcinoma

Answer

Carcinoma base of tongue

Answer

Carcinoma lip

Question 8

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?

Accepted Answer

Topoisomerase inhibitors promote the unwinding of parental DNA strands and prevent replication.

Answer

The drugs used are designed to block DNA replication.

Answer

Methotrexate and 5-fluorouracil block nucleotide synthesis.

Answer

The drugs used for cancer therapy inhibit the enzymes that participate in replication.

Question 9

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

Accepted Answer

Surgery and Radiotherapy

Answer

Surgery

Answer

Radiotherapy

Answer

Surgery and chemotherapy

Question 10

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

Accepted Answer

All of the above

Answer

Smoking

Answer

Alcohol

Answer

Syphilis

ENT Oncology — MCQs

ENT Oncology — MCQs

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