ENT Oncology — MCQs

A 55-year-old male patient complains of an abnormal growth on his right cheek. The patient has a habit of tobacco chewing for 30 years. Radiologic findings reveal an 8x8 cm fungating mass invading the maxilla and mandible on the right side. The patient was advised palliative chemotherapy with cisplatin. Which of the following changes in DNA is NOT caused by this drug?

ENT Oncology Indian Medical PG Practice Questions and MCQs

Question 61: A 14-year-old boy presents with a history of frequent nasal bleeding. His Hb was found to be 6.4 g/dL and peripheral smear showed normocytic hypochromic anemia. What is the most probable diagnosis?

A. Juvenile nasopharyngeal angiofibroma (Correct Answer)
B. Hemangioma
C. Antrochoanal polyp
D. Carcinoma of nasopharynx

Explanation: **Explanation:** The clinical presentation of a **14-year-old male** with **frequent, profuse nasal bleeding (epistaxis)** leading to significant **secondary anemia** (Hb 6.4 g/dL) is a classic "textbook" description of **Juvenile Nasopharyngeal Angiofibroma (JNA)**. **1. Why JNA is the correct answer:** JNA is a benign but locally aggressive, highly vascular tumor that occurs almost exclusively in **adolescent males**. It typically originates in the sphenopalatine foramen. The hallmark symptom is spontaneous, painless, and recurrent profuse epistaxis. The severity of bleeding often leads to chronic iron-deficiency anemia (normocytic hypochromic), as seen in this patient. **2. Why other options are incorrect:** * **Hemangioma:** While vascular, they usually present as smaller, localized lesions on the nasal septum (Little’s area) and rarely cause anemia this severe in an adolescent. * **Antrochoanal polyp:** These present primarily with unilateral nasal obstruction. While they may cause minor mucoid discharge, they do not cause profuse bleeding or systemic anemia. * **Carcinoma of nasopharynx:** While it can cause bleeding, it is rare in this age group and typically presents with a neck mass (level II nodes), hearing loss (serous otitis media), or cranial nerve palsies. **3. High-Yield Clinical Pearls for NEET-PG:** * **Holman-Miller Sign:** Anterior bowing of the posterior wall of the maxillary sinus seen on CT (pathognomonic). * **Diagnosis:** Biopsy is **contraindicated** due to the risk of fatal hemorrhage. Diagnosis is clinical and radiological (Contrast CT/MRI). * **Blood Supply:** Most commonly the **Internal Maxillary Artery** (branch of External Carotid). * **Treatment of Choice:** Surgical excision (usually preceded by preoperative embolization to reduce blood loss).

Question 62: Which of the following is NOT a complication of oropharyngeal resection?

A. Xerostomia (Correct Answer)
B. Thoracic duct injury
C. Soft-tissue edema
D. Rupture of carotid artery

Explanation: **Explanation:** The correct answer is **A. Xerostomia**. **1. Why Xerostomia is the correct answer:** Xerostomia (dry mouth) is primarily a complication of **Radiotherapy (RT)**, not the surgical resection itself. During radiation for oropharyngeal tumors, the parotid and submandibular salivary glands are often within the radiation field, leading to acinar atrophy and fibrosis. While surgical resection involves removing tissue, it does not typically result in the global loss of salivary function unless all major salivary glands are bilaterally excised, which is not standard for oropharyngeal resection. **2. Analysis of Incorrect Options (Surgical Complications):** * **Thoracic duct injury:** This is a known risk during neck dissection (especially on the left side) which often accompanies oropharyngeal resection. It can lead to a chyle leak. * **Soft-tissue edema:** Extensive surgical manipulation, lymphatic disruption, and venous congestion post-resection commonly lead to significant airway and facial edema, often necessitating a temporary tracheostomy. * **Rupture of carotid artery:** This is a dreaded "catastrophic" complication. It usually occurs due to wound infection, salivary fistula (saliva bathing the artery), or necrosis of the skin flaps covering the vessel. **3. NEET-PG High-Yield Pearls:** * **Most common site** of oropharyngeal cancer: Palatine tonsils (followed by the base of the tongue). * **Carotid Blowout:** The risk increases significantly if the patient has had prior radiation or develops a pharyngocutaneous fistula. * **Pilocarpine:** Often used to treat radiation-induced xerostomia as it acts as a sialagogue. * **TNM Staging:** Oropharyngeal cancers are now staged differently based on **p16 (HPV) status**, as HPV-positive tumors have a significantly better prognosis.

Question 63: What is the most appropriate investigation for angiofibroma?

A. Angiography
B. CT scan (Correct Answer)
C. MRI scan
D. Plain X-ray

Explanation: **Explanation:** Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign but locally aggressive, highly vascular tumor typically seen in adolescent males. **1. Why CT Scan is the Correct Answer:** Contrast-enhanced CT (CECT) scan is considered the **investigation of choice** for JNA. It is superior for assessing the extent of the tumor and its impact on the surrounding bony architecture. The hallmark radiological sign on CT is the **Holman-Miller sign** (or antral sign), which is the anterior bowing of the posterior wall of the maxillary sinus. CT provides the necessary anatomical detail for surgical planning, especially regarding bone erosion at the base of the skull. **2. Analysis of Incorrect Options:** * **Angiography:** While it is the **most specific** investigation (showing a characteristic "tumor blush"), it is not the initial investigation of choice. Its primary role is diagnostic confirmation and, more importantly, **pre-operative embolization** to reduce intraoperative blood loss. * **MRI Scan:** MRI is superior for evaluating soft tissue extension, specifically intracranial spread or involvement of the cavernous sinus and orbit. However, it is usually complementary to CT. * **Plain X-ray:** This is an obsolete modality. While it may show a soft tissue mass or the Holman-Miller sign, it lacks the detail required for modern management. **3. Clinical Pearls for NEET-PG:** * **Biopsy is contraindicated:** Due to the risk of torrential hemorrhage, a biopsy should never be performed in a suspected case of JNA. * **Origin:** Most commonly arises from the superior margin of the **sphenopalatine foramen**. * **Classic Triad:** Adolescent male + Recurrent profuse epistaxis + Nasal obstruction. * **Treatment:** Surgical excision (Transpalatal, Endoscopic, or Maxillary swing) preceded by embolization.

Question 64: Adenocarcinoma of the ethmoid sinus occurs commonly in:

A. Fire workers
B. Chimney workers
C. Watch makers
D. Wood workers (Correct Answer)

Explanation: **Explanation:** The association between **wood dust exposure** and **Adenocarcinoma of the ethmoid sinus** is a classic high-yield association in ENT oncology. **1. Why Wood Workers?** Chronic inhalation of fine hardwood dust (specifically oak, beech, and mahogany) is a well-established carcinogen for the nasal cavity and paranasal sinuses. The dust particles tend to deposit on the middle turbinate and the ethmoid air cells. Over years of exposure (often 20–40 years), this leads to chronic inflammation, squamous metaplasia, and eventually the development of **Adenocarcinoma** (specifically the intestinal type). **2. Analysis of Incorrect Options:** * **Fire workers:** While exposed to heat and smoke, there is no specific link to ethmoid adenocarcinoma. * **Chimney workers:** Classically associated with **Squamous Cell Carcinoma of the Scrotum** (Pott’s Cancer) due to soot and polycyclic aromatic hydrocarbons (PAHs). * **Watch makers:** This occupation involves fine mechanical work but lacks exposure to specific inhaled carcinogens related to sinus malignancy. **3. Clinical Pearls for NEET-PG:** * **Most common Sinus Malignancy:** Squamous Cell Carcinoma (SCC) is the most common overall, usually affecting the **Maxillary Sinus**. * **Ethmoid Sinus:** Adenocarcinoma is the most common primary malignancy here, specifically linked to wood dust. * **Nickel workers:** Associated with both SCC and Anaplastic carcinoma of the nasal cavity. * **Leather/Shoe workers:** Also have an increased risk of nasal Adenocarcinoma (due to tanning agents). * **Isopropanol manufacture:** Linked to an increased risk of sinus cancers. * **Clinical Presentation:** Usually presents with unilateral nasal obstruction, epistaxis, or cheek swelling.

Question 65: Ohngren's classification of maxillary sinus carcinoma is based on which anatomical landmark or plane?

A. An imaginary plane between the medial canthus of the eye and the angle of the mandible (Correct Answer)
B. An imaginary plane between the lateral canthus of the eye and the angle of the mandible
C. Two horizontal lines, one passing through the floor of the orbit and the other through the floor of the antrum
D. None of the above

Explanation: **Explanation:** **Ohngren’s Classification** is a prognostic tool used to divide the maxillary sinus into two segments based on an imaginary anatomical line. 1. **Why Option A is correct:** Ohngren’s line is an imaginary plane extending from the **medial canthus of the eye to the angle of the mandible**. This plane divides the maxillary antrum into: * **Anteroinferior (Infrastructure):** Tumors here have a better prognosis as they are more accessible and present earlier with dental or cheek symptoms. * **Posterosuperior (Suprastructure):** Tumors here have a poorer prognosis because they involve critical structures like the ethmoid sinuses, orbit, and pterygopalatine fossa early in the disease. 2. **Why other options are incorrect:** * **Option B:** The lateral canthus is not used in this classification; using it would shift the plane too far posteriorly, failing to capture the clinically significant division of the antrum. * **Option C:** This describes **Lederman’s Classification**, which uses two horizontal lines to divide the nasal and paranasal areas into three regions (suprastructure, mesostructure, and infrastructure). **High-Yield Clinical Pearls for NEET-PG:** * **Prognostic Significance:** Tumors located **above and behind** Ohngren’s line (Suprastructure) have the worst prognosis due to early intracranial and orbital spread. * **Most common histology:** Squamous Cell Carcinoma is the most common malignancy of the maxillary sinus. * **Clinical Presentation:** The most common symptom of maxillary sinus cancer is nasal obstruction or blood-stained discharge, but "cheek swelling" is a classic sign of anterior extension. * **Staging:** While Ohngren’s is historical/prognostic, the TNM staging (AJCC) is currently used for definitive management.

Question 66: Hypopharyngeal tumors have a poor prognosis compared with other head and neck cancer sites because of all except:

A. Vague early stage symptoms
B. Locally advanced stage at presentation
C. High rate of nodal metastasis
D. Low rate of distant metastasis (Correct Answer)

Explanation: Hypopharyngeal tumors are notorious for having the worst prognosis among all head and neck cancers. The correct answer is **D (Low rate of distant metastasis)** because, in reality, hypopharyngeal cancers have a **high rate of distant metastasis** (up to 20-25%), most commonly to the lungs, liver, and bones. ### Why the other options are incorrect (Reasons for poor prognosis): * **Vague early-stage symptoms (Option A):** The hypopharynx is a "silent" area. Early symptoms like a mild foreign body sensation or "prickling" in the throat are often ignored by patients, leading to diagnostic delays. * **Locally advanced stage at presentation (Option B):** Due to the distensible nature of the pyriform sinus and lack of early functional impairment (like hoarseness), roughly 70-80% of patients present at Stage III or IV. * **High rate of nodal metastasis (Option C):** The hypopharynx has an incredibly rich lymphatic network. Approximately 50-70% of patients have clinically palpable cervical lymph nodes at the time of diagnosis, and many have bilateral or contralateral spread. ### Clinical Pearls for NEET-PG: * **Most common site:** Pyriform sinus (approx. 70%), followed by the post-cricoid region and posterior pharyngeal wall. * **Post-cricoid carcinoma:** Classically associated with **Plummer-Vinson Syndrome** (Paterson-Brown-Kelly Syndrome) and predominantly seen in non-smoking females. * **Pryiform Sinus:** Known as the "Smuggler’s area" because tumors can grow to a large size here without causing significant symptoms. * **Prognostic Factor:** The presence of extracapsular spread in lymph nodes is a major negative prognostic indicator.

Question 67: Ohgren's line passes from which anatomical landmark to which other anatomical landmark?

A. Medial canthus to the angle of the mandible (Correct Answer)
B. Lateral canthus to the angle of the mandible
C. Medial canthus to the mastoid process
D. Lateral canthus to the mastoid process

Explanation: ### Explanation **Ohgren’s line** is a theoretical plane used in the classification and prognosis of maxillary sinus tumors. It is an imaginary line extending from the **medial canthus of the eye to the angle of the mandible**. #### 1. Why Option A is Correct This line divides the maxillary sinus into two distinct clinical compartments: * **Anteroinferior (Infrastructure):** Tumors located below and in front of this line generally have a **better prognosis** because they are more accessible surgically and present earlier with dental or cheek symptoms. * **Posterosuperior (Suprastructure):** Tumors located above and behind this line have a **poorer prognosis** as they tend to invade critical structures like the orbit, ethmoid sinuses, and pterygopalatine fossa early in the disease course. #### 2. Why Other Options are Incorrect * **Options B, C, and D:** These combinations of landmarks (Lateral canthus and Mastoid process) do not correspond to any recognized clinical classification system for paranasal sinus oncology. The medial canthus is the critical superior landmark because it marks the boundary near the ethmoid labyrinth and orbital apex. #### 3. Clinical Pearls for NEET-PG * **Prognostic Significance:** The most important takeaway is that tumors crossing Ohgren’s line posterosuperiorly carry a high risk of base-of-skull involvement. * **Lederman’s Classification:** Another high-yield system that uses two horizontal lines (passing through the floor of the orbit and the floor of the antrum) to divide the area into suprastructure, mesostructure, and infrastructure. * **Most Common Histology:** Squamous cell carcinoma is the most common malignancy of the maxillary antrum. * **TNM Staging:** Remember that T4a involves the skin of the cheek or pterygoid plates, while T4b involves the orbital apex or brain.

Question 68: Which of the following is not typically seen in Nasopharyngeal Carcinoma?

A. Headache
B. Diplopia
C. Lymph node involvement
D. Sneezing episodes (Correct Answer)

Explanation: **Explanation:** Nasopharyngeal Carcinoma (NPC) typically arises from the **Fossa of Rosenmüller**. It is characterized by an insidious onset and often presents with symptoms related to local invasion, Eustachian tube obstruction, or distant metastasis, rather than acute inflammatory rhinitis symptoms like sneezing. **Why "Sneezing episodes" is the correct answer:** Sneezing is a protective reflex mediated by the trigeminal nerve, usually triggered by mucosal irritation in the anterior nasal cavity (e.g., allergic rhinitis or viral infections). NPC originates in the nasopharynx (posterior to the nasal cavity); while it can cause nasal obstruction or epistaxis, it does not typically trigger the sneezing reflex. **Analysis of incorrect options:** * **Headache:** This is a common symptom caused by erosion of the skull base or infiltration of the trigeminal nerve (V1/V2 branches). * **Diplopia:** NPC frequently invades the cavernous sinus via the Foramen Lacerum. The **Abducens nerve (VI)** is the most commonly affected cranial nerve, leading to lateral rectus palsy and double vision. * **Lymph node involvement:** This is the **most common presenting feature** (up to 75% of cases). The nodes involved are typically the upper deep cervical and the **Node of Rouviere** (lateral retropharyngeal node). **High-Yield Clinical Pearls for NEET-PG:** 1. **Trotter’s Triad:** Diagnostic for NPC—includes (1) Conductive deafness (serous otitis media), (2) Ipsilateral temporofacial neuralgia (CN V pain), and (3) Palatal paralysis (CN X). 2. **Etiology:** Strongly associated with **Epstein-Barr Virus (EBV)** and dietary factors like salted fish (nitrosamines). 3. **Treatment of Choice:** Radiotherapy is the primary modality (NPC is highly radiosensitive). Surgery is reserved for salvage.

Question 69: Metastasis of carcinoma of the buccal mucosa typically goes to which of the following?

A. Regional lymph nodes (Correct Answer)
B. Liver
C. Heart
D. Brain

Explanation: **Explanation:** **1. Why Regional Lymph Nodes is Correct:** Carcinoma of the buccal mucosa, like most Squamous Cell Carcinomas (SCC) of the head and neck, primarily spreads via the **lymphatic route** before it ever spreads hematogenously. The buccal mucosa has a rich lymphatic network that drains primarily into the **Submandibular (Level IB)** and **Upper Deep Cervical (Level II)** lymph nodes. In clinical practice, the presence of regional nodal metastasis is the most significant prognostic factor for survival in oral cavity cancers. **2. Why the Other Options are Incorrect:** * **B. Liver:** While the liver is a common site for distant (systemic) metastasis in many visceral cancers, it is rare in buccal SCC. Distant metastasis usually occurs only in advanced stages (Stage IV) after regional lymph node involvement. * **C. Heart:** Metastasis to the heart is extremely rare for any head and neck malignancy. * **D. Brain:** Brain metastasis is uncommon for oral cancers. If distant spread occurs, the **lungs** are the most common site, followed by the bones and liver. **Clinical Pearls for NEET-PG:** * **Most common site of distant metastasis:** Lungs (not liver). * **Staging Tip:** The "N" in TNM staging for oral cancer is determined by the size, number, and extranodal extension of these regional lymph nodes. * **Risk Factors:** In the Indian context, "Chutta" smoking and betel nut (pan masala) chewing are the leading causes of buccal mucosa SCC. * **Field Cancerization:** This concept (by Slaughter et al.) explains why patients with one oral lesion are at high risk for developing secondary primary tumors in the same region.

Question 70: A 55-year-old male patient complains of an abnormal growth on his right cheek. The patient has a habit of tobacco chewing for 30 years. Radiologic findings reveal an 8x8 cm fungating mass invading the maxilla and mandible on the right side. The patient was advised palliative chemotherapy with cisplatin. Which of the following changes in DNA is NOT caused by this drug?

A. A-tracts are replaced by other bases
B. Collapse of the helix into the minor groove of A-tract
C. Production of bent structures in DNA
D. The changed structure cannot bind proteins (Correct Answer)

Explanation: **Explanation:** **Cisplatin** is a platinum-based alkylating-like agent used extensively in ENT oncology for squamous cell carcinomas. Its mechanism of action involves the formation of **intra-strand cross-links** (primarily between adjacent Guanine bases). **Why Option D is Correct:** The core concept is that Cisplatin-induced DNA damage **does not prevent protein binding**; instead, it facilitates the binding of specific proteins. When Cisplatin creates DNA adducts, it causes significant structural distortion (bending). This distorted DNA is specifically recognized and bound by **High Mobility Group (HMG) domain proteins** and other DNA-repair proteins. These proteins "shield" the DNA from repair mechanisms, ultimately leading to programmed cell death (apoptosis). Therefore, saying the structure *cannot* bind proteins is factually incorrect. **Analysis of Incorrect Options:** * **Option A & B:** Cisplatin has a high affinity for specific sequences. It targets G-rich areas and can lead to the disruption of **A-tracts** (sequences of adenine). The resulting cross-links cause a structural **collapse of the DNA helix** into the minor groove, particularly affecting the geometry of A-tracts. * **Option C:** The hallmark of Cisplatin action is the **bending of the DNA duplex** (approximately 30-90 degrees). This bending is essential for its cytotoxic effect as it signals the cell's apoptotic machinery. **Clinical Pearls for NEET-PG:** * **Dose-limiting toxicity:** Nephrotoxicity (prevented by aggressive hydration and Amifostine). * **Other toxicities:** Ototoxicity (high-frequency hearing loss), peripheral neuropathy, and severe emesis (highly emetogenic). * **Mechanism:** Forms **1,2-intrastrand cross-links** (most common) rather than interstrand links.

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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