ENT Oncology — MCQs

ENT Oncology Indian Medical PG Practice Questions and MCQs

Question 71: Secondaries in the neck with no obvious primary malignancy is most often due to?

A. Carcinoma of Stomach
B. Carcinoma of Larynx
C. Carcinoma of Nasopharynx (Correct Answer)
D. Carcinoma of Thyroid

Explanation: **Explanation:** The clinical scenario described is a **"Cervical Metastasis with Unknown Primary" (CUP).** In the context of ENT oncology, when a patient presents with a neck mass that is biopsy-proven squamous cell carcinoma but no obvious lesion is visible on routine examination, the **Nasopharynx** is the most common site of the occult primary. **1. Why Nasopharynx is the Correct Answer:** * **Anatomical Location:** The nasopharynx is a "silent" area. Tumors here often remain asymptomatic for a long time because they do not interfere with swallowing or speech initially. * **Lymphatic Drainage:** The nasopharynx has an extremely rich lymphatic network. Metastasis to the **Level II or Level V (posterior triangle)** lymph nodes is often the first and only clinical sign of the disease. * **Occult Nature:** Small, submucosal lesions in the Fossa of Rosenmüller can be easily missed during a standard physical exam, making it the classic "hidden" primary. **2. Analysis of Incorrect Options:** * **Carcinoma of Stomach:** While it can present with a left supraclavicular node (**Virchow’s node**), it is an infra-diaphragmatic primary and is less common than head and neck primaries for general neck secondaries. * **Carcinoma of Larynx:** These usually present early with symptoms like **hoarseness of voice**, making the primary "obvious" rather than occult. * **Carcinoma of Thyroid:** While it frequently spreads to the neck, the primary is usually detectable via palpation or ultrasound, and the histology (papillary/follicular) differs from the typical squamous cell carcinoma seen in unknown primaries. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site for occult primary:** Nasopharynx, followed by the Base of Tongue and Palatine Tonsil. * **Diagnostic Gold Standard:** If the primary is not found after imaging (PET-CT), a **"Panendoscopy"** with directed biopsies of the nasopharynx, base of tongue, and tonsillectomy is performed. * **EBV Association:** Nasopharyngeal carcinoma is strongly associated with the **Epstein-Barr Virus (EBV).**

Question 72: A 70-year-old male presents with neck nodes. Examination reveals a dull tympanic membrane, deafness, and tinnitus. Audiometry gives Curve B. What is the most probable diagnosis?

A. Nasopharyngeal carcinoma (Correct Answer)
B. Fluid in middle ear
C. Tumor in the inner ear
D. Sensorineural hearing loss

Explanation: ### Explanation The clinical presentation describes **Trotter’s Triad**, a classic diagnostic cluster for **Nasopharyngeal Carcinoma (NPC)**. **1. Why Nasopharyngeal Carcinoma is correct:** In an elderly patient, a mass in the nasopharynx (often originating in the Fossa of Rosenmüller) can obstruct the opening of the **Eustachian tube**. This leads to negative middle ear pressure and subsequent **Serous Otitis Media (Otitis Media with Effusion)**. * **Clinical signs:** Dull tympanic membrane, conductive deafness, and tinnitus. * **Tympanometry:** A **Type B curve** (flat curve) specifically indicates fluid in the middle ear or a non-compliant system, consistent with effusion. * **Neck Nodes:** NPC frequently metastasizes to the upper deep cervical nodes (Level II/III), often presenting as a painless neck lump. **2. Why other options are incorrect:** * **Fluid in the middle ear:** While this explains the ear symptoms and Curve B, it is a *finding*, not the primary *diagnosis* in a 70-year-old with neck nodes. In an elderly patient, unilateral serous otitis media is NPC until proven otherwise. * **Tumor in the inner ear:** This would typically present with vertigo and profound sensorineural hearing loss, not a dull TM or a Type B tympanogram. * **Sensorineural hearing loss:** This would yield a **Type A curve** (normal middle ear pressure) and would not explain the dull TM or neck nodes. **Clinical Pearls for NEET-PG:** * **Trotter’s Triad:** (1) Conductive deafness (Eustachian tube block), (2) Ipsilateral soft palate paralysis (CN X involvement), and (3) Trigeminal neuralgia (CN V involvement). * **EBV Association:** NPC is strongly linked to the Epstein-Barr Virus. * **Rule of Thumb:** Any adult presenting with unilateral serous otitis media must undergo a fiberoptic nasopharyngoscopy to rule out malignancy.

Question 73: Which of the following is an important etiological factor for nasopharyngeal carcinoma?

A. Cytomegalovirus
B. Epstein Barr virus (Correct Answer)
C. Human Herpes Virus
D. Varicella

Explanation: **Explanation:** **Nasopharyngeal Carcinoma (NPC)** is a unique head and neck malignancy with a strong association with the **Epstein-Barr Virus (EBV)**. 1. **Why Option B is Correct:** EBV (Human Herpesvirus 4) is the primary etiological agent, particularly for the **WHO Type 2 (non-keratinizing)** and **WHO Type 3 (undifferentiated)** variants. The viral genome is found within the tumor cells, and EBV-encoded proteins (like LMP-1) drive oncogenesis by inhibiting apoptosis and promoting cell proliferation. Serological markers, such as **IgA antibodies against Viral Capsid Antigen (VCA)** and Early Antigen (EA), are used for screening and monitoring recurrence. 2. **Why Other Options are Incorrect:** * **Option A (CMV) & Option C (HHV):** While these belong to the Herpesviridae family, they are not oncogenic in the context of the nasopharynx. CMV is typically associated with congenital infections or opportunistic infections in immunocompromised states. * **Option D (Varicella):** Varicella-Zoster Virus (HHV-3) causes chickenpox and shingles; it has no known association with malignant transformation. **High-Yield Clinical Pearls for NEET-PG:** * **Epidemiology:** Highest incidence is seen in Southern China (Guangdong province) due to genetic susceptibility and dietary factors (nitrosamines in salted fish). * **Clinical Presentation:** The most common presenting symptom is a **painless upper deep cervical lymph node** (Level II/III). Other features include unilateral serous otitis media (due to Eustachian tube blockage) and Fossae of Rosenmüller involvement. * **Trotter’s Triad:** 1. Conductive deafness, 2. Ipsilateral temporoparietal neuralgia (CN V involvement), 3. Palatal paralysis (CN X involvement). * **Treatment:** Radiotherapy is the treatment of choice as NPC is highly radiosensitive.

Question 74: Trotter's triad is seen in which of the following conditions?

A. Nasopharyngeal angiofibroma
B. Nasal polyposis
C. Nasopharyngeal carcinoma (Correct Answer)
D. Acoustic neuroma

Explanation: **Explanation:** **Trotter’s Triad** is a classic clinical diagnostic cluster associated with the lateral spread of **Nasopharyngeal Carcinoma (NPC)**, specifically when the tumor invades the parapharyngeal space and involves the mandibular nerve (CN V3) and the Eustachian tube. The triad consists of: 1. **Conductive Hearing Loss:** Due to Eustachian tube blockage leading to serous otitis media. 2. **Ipsilateral Neuralgia:** Pain in the lower jaw, tongue, and side of the head due to involvement of the **Mandibular Nerve (V3)**. 3. **Palatal Paralysis/Immobility:** Due to infiltration of the **Levator Veli Palatini** muscle. **Analysis of Options:** * **Nasopharyngeal Angiofibroma (Option A):** A benign but locally aggressive vascular tumor in adolescent males. It typically presents with profuse epistaxis and nasal obstruction, not the specific neurological/palatal findings of Trotter’s Triad. * **Nasal Polyposis (Option B):** Non-neoplastic masses of the nasal mucosa. They present with anosmia and obstruction but do not invade deep spaces or nerves. * **Acoustic Neuroma (Option D):** A tumor of the 8th cranial nerve. It presents with sensorineural hearing loss, tinnitus, and vertigo, rather than conductive loss and palatal palsy. **High-Yield Clinical Pearls for NEET-PG:** * **Fossa of Rosenmüller:** The most common site of origin for Nasopharyngeal Carcinoma. * **EBV Association:** NPC is strongly linked to the Epstein-Barr Virus. * **Nodal Involvement:** The most common presenting symptom of NPC is actually a painless upper cervical lymph node mass (Level II/Jugulodigastric). * **Treatment of Choice:** Radiotherapy is the primary treatment for NPC, as it is highly radiosensitive.

Question 75: All of the following statements about Lymphoepithelioma are true, except?

A. Parotid gland is the most common site of Lymphoepithelioma in the Head & Neck region. (Correct Answer)
B. It is associated with EBV infection.
C. It is highly radiosensitive.
D. It is a type of squamous cell carcinoma.

Explanation: **Explanation:** **Lymphoepithelioma** (also known as Undifferentiated Nasopharyngeal Carcinoma, WHO Type III) is a specific subtype of non-keratinizing squamous cell carcinoma characterized by a dense reactive lymphocytic infiltrate. **1. Why Option A is the correct answer (The False Statement):** The **Nasopharynx** (specifically the Fossa of Rosenmüller) is the most common site for Lymphoepithelioma in the head and neck, not the parotid gland. While "Lymphoepithelioma-like carcinoma" (LELC) can occur in the salivary glands, it is rare and typically represents less than 1% of salivary tumors. **2. Analysis of other options:** * **Option B (EBV Association):** There is a very strong, nearly 100% association between Lymphoepithelioma and **Epstein-Barr Virus (EBV)**. Serum titers of IgA against Viral Capsid Antigen (VCA) are used for screening and monitoring recurrence. * **Option C (Radiosensitivity):** Unlike typical keratinizing squamous cell carcinomas, Lymphoepitheliomas are **highly radiosensitive** and chemosensitive. Radiotherapy is the primary treatment modality for the local site and neck nodes. * **Option D (Type of SCC):** Pathologically, it is classified as a **Type III Undifferentiated Squamous Cell Carcinoma** (WHO classification). The "lympho" part of the name refers to the heavy background of non-neoplastic T-cells, but the malignant cells are epithelial. **High-Yield Clinical Pearls for NEET-PG:** * **Bimodal Age Distribution:** Peaks at 15–25 years and 40–60 years. * **Trotter’s Triad:** Conductive hearing loss (serous otitis media), Ipsilateral facial pain (Trigeminal neuralgia), and Palatal paralysis. * **Most Common Presenting Symptom:** Painless upper deep cervical lymphadenopathy (Level II/III). * **Diagnostic Marker:** EBV-encoded RNA (EBER) via in-situ hybridization is the gold standard for identifying the virus in tissue samples.

Question 76: Trismus in carcinoma of the temporal bone occurs due to involvement of which structure?

A. Dura
B. Temporomandibular joint (Correct Answer)
C. Mastoid
D. Eustachian tube

Explanation: **Explanation:** In the context of temporal bone carcinoma (most commonly Squamous Cell Carcinoma), the development of **trismus** (difficulty in opening the mouth) is a significant clinical sign indicating **anterior extension** of the tumor. 1. **Why the TMJ is correct:** The anterior wall of the external auditory canal (EAC) is in direct anatomical proximity to the **Temporomandibular Joint (TMJ)** and the parotid gland. When a tumor erodes through the anterior bony or cartilaginous wall of the EAC, it invades the TMJ or the pterygoid muscles. This invasion causes pain and mechanical restriction of the mandible, leading to trismus. 2. **Why other options are incorrect:** * **Dura:** Involvement of the dura signifies superior extension into the middle cranial fossa. This leads to neurological deficits or CSF otorrhea, not trismus. * **Mastoid:** Posterior extension into the mastoid air cells typically causes retroauricular pain or swelling but does not affect the muscles of mastication. * **Eustachian tube:** While the tumor can involve the Eustachian tube leading to middle ear effusion/hearing loss, it does not mechanically restrict jaw movement. **Clinical Pearls for NEET-PG:** * **Staging:** According to the Modified Pittsburgh Staging System, involvement of the TMJ or erosion of the EAC wall usually classifies the tumor as **T3**. * **Most Common Site:** The External Auditory Canal is the most common site of origin for temporal bone malignancy. * **Red Flag:** Chronic otorrhea that is blood-stained and associated with severe deep-seated pain should always raise suspicion of malignancy. * **Facial Nerve:** Facial nerve palsy is a poor prognostic sign indicating deep infiltration into the petrous bone (T4).

Question 77: Radiotherapy is the treatment of choice for which of the following conditions?

A. Nasopharyngeal carcinoma T3N1 (Correct Answer)
B. Supraglottic carcinoma T3N0
C. Glottic carcinoma T3N1
D. Subglottic carcinoma T3N0

Explanation: **Explanation:** **1. Why Nasopharyngeal Carcinoma (NPC) is the Correct Answer:** Nasopharyngeal carcinoma is unique among head and neck cancers because it is **highly radiosensitive** and **chemosensitive**. Due to its anatomical location (deep-seated, proximity to the skull base) and its tendency for early bilateral lymphatic spread, surgery is technically difficult and rarely the primary treatment. For Stage T3N1 (Stage III), the standard of care is **Concurrent Chemoradiotherapy (CCRT)**. Radiotherapy remains the backbone of treatment for all stages of NPC, unlike other head and neck sites where advanced stages often require surgery. **2. Why the Other Options are Incorrect:** * **B, C, and D (Laryngeal Carcinomas - T3):** According to the TNM staging and management protocols for Laryngeal cancer (Supraglottic, Glottic, and Subglottic), **T3 lesions** signify advanced local disease (e.g., vocal cord fixation or invasion of the pre-epiglottic space). The standard treatment for T3 laryngeal tumors is usually **Total Laryngectomy** followed by postoperative radiotherapy, or organ preservation protocols using concurrent chemoradiotherapy. However, surgery is often preferred for T3/T4 subglottic and supraglottic lesions due to poorer responses to radiation alone compared to NPC. **3. Clinical Pearls for NEET-PG:** * **Treatment of Choice (TOC):** For NPC, RT is the TOC for early stages (T1), while CCRT is the TOC for advanced stages (T2-T4). * **Surgery in NPC:** Surgery (Nasopharyngectomy) is reserved only for **recurrent or residual disease** (Salvage surgery). * **EBV Association:** NPC (especially Type II and III) is strongly associated with the **Epstein-Barr Virus**. * **Fossa of Rosenmüller:** This is the most common site of origin for NPC. * **Trotter’s Triad:** Conductive deafness, Ipsilateral temporofacial neuralgia (CN V invasion), and Palatal paralysis (CN X invasion) are diagnostic features of NPC.

Question 78: Nasopharyngeal carcinoma is caused by which virus?

A. Epstein-Barr virus (EBV) (Correct Answer)
B. Human papillomavirus (HPV)
C. Herpes simplex virus (HSV)
D. Varicella-zoster virus (VZV)

Explanation: **Explanation:** **Nasopharyngeal Carcinoma (NPC)** is strongly associated with the **Epstein-Barr Virus (EBV)**, particularly the undifferentiated type (WHO Type 3). The virus infects B-lymphocytes and nasopharyngeal epithelial cells, where it remains latent. The expression of specific viral genes, such as **LMP-1 (Latent Membrane Protein 1)**, triggers oncogenic transformation by inhibiting apoptosis and promoting cell proliferation. EBV DNA levels and antibody titers (especially IgA against Viral Capsid Antigen) are used clinically as biomarkers for screening, prognosis, and monitoring recurrence. **Analysis of Incorrect Options:** * **Human papillomavirus (HPV):** While HPV (specifically types 16 and 18) is a major cause of **Oropharyngeal squamous cell carcinoma** (tonsils and base of tongue), it is not the primary driver for Nasopharyngeal carcinoma. * **Herpes simplex virus (HSV):** HSV-1 and HSV-2 are primarily associated with oral and genital herpetic lesions (vesicles) and encephalitis, not oncogenesis in the nasopharynx. * **Varicella-zoster virus (VZV):** This virus causes chickenpox and shingles. It does not have a known association with head and neck malignancies. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Fossa of Rosenmüller. * **Classic Triad (Trotter’s Triad):** 1. Conductive hearing loss (due to Eustachian tube blockage), 2. Ipsilateral palatal paralysis, 3. Trigeminal neuralgia (facial pain). * **Treatment of Choice:** Radiotherapy (NPC is highly radiosensitive). * **Histology:** The WHO classification Type 3 (Undifferentiated) is the most common and has the strongest link to EBV.

Question 79: Temporal bone metastasis is most commonly seen with which primary malignancy?

A. Carcinoma of the breast
B. Carcinoma of the bronchus (Correct Answer)
C. Carcinoma of the kidney
D. Carcinoma of the prostate

Explanation: **Explanation:** Temporal bone metastasis is a rare but clinically significant occurrence. While the temporal bone is an uncommon site for secondary deposits compared to the axial skeleton, it can be involved via hematogenous spread or direct extension. **1. Why Carcinoma of the Bronchus is correct:** Statistically, **Carcinoma of the Bronchus (Lung)** is the most common primary malignancy to metastasize to the temporal bone. This is attributed to the high incidence of lung cancer and its propensity for early hematogenous dissemination through the systemic circulation. In most clinical series and histopathological studies, lung cancer (in males) and breast cancer (in females) are the top two; however, when considering the overall population in recent ENT literature, bronchogenic carcinoma remains the leading primary site. **2. Analysis of Incorrect Options:** * **Carcinoma of the Breast (Option A):** This is the second most common cause overall and the **most common in females**. If the question specifically asked for the most common primary in women, this would be the answer. * **Carcinoma of the Kidney (Option C):** Renal cell carcinoma (RCC) is known for its "hypervascular" metastases. While it can spread to the temporal bone, it is less frequent than lung or breast primaries. * **Carcinoma of the Prostate (Option D):** Prostate cancer typically spreads to the pelvic bones and lumbar spine (blastic lesions). Temporal bone involvement is rare. **Clinical Pearls for NEET-PG:** * **Most common site within the temporal bone:** The **Petrous Apex** (due to its rich marrow content and vascularity). * **Common symptoms:** Hearing loss (conductive or sensorineural), facial nerve palsy, and otalgia. * **Radiological sign:** Usually presents as an osteolytic lesion (except for prostate/breast, which may be osteoblastic). * **Key Association:** If a patient presents with sudden onset of multiple cranial nerve palsies and a history of smoking, always suspect temporal bone metastasis from the lung.

Question 80: Non-keratinized squamous cell carcinoma of the nasopharynx belongs to which WHO classification type?

A. Type 1
B. Type 2 (Correct Answer)
C. Type 3
D. Type 4

Explanation: **Explanation:** The World Health Organization (WHO) classifies Nasopharyngeal Carcinoma (NPC) into three distinct histological types based on the degree of differentiation and keratinization: * **Type 1: Keratinized Squamous Cell Carcinoma.** This type shows clear evidence of keratinization (keratin pearls). It is least associated with Epstein-Barr Virus (EBV) and has the strongest link to smoking and alcohol. It has the poorest prognosis due to low radiosensitivity. * **Type 2: Non-keratinized Squamous Cell Carcinoma.** This type consists of cells that show definite squamous differentiation (e.g., intercellular bridges) but **lack** overt keratinization. This matches the question's requirement. * **Type 3: Undifferentiated Carcinoma.** This is the most common type worldwide (often called Lymphoepithelioma). It shows no squamous or glandular differentiation. It has the strongest association with EBV titers and is highly radiosensitive, leading to a better prognosis. **Why other options are incorrect:** * **Option A (Type 1):** Incorrect because it refers specifically to the **keratinizing** variety. * **Option C (Type 3):** Incorrect because it refers to **undifferentiated** cells where squamous features are absent. * **Option D (Type 4):** Incorrect as there is no "Type 4" in the standard WHO classification for NPC. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Fossa of Rosenmüller. * **Triad of Trotter:** Conductive hearing loss (serous otitis media), ipsilateral facial/palatal paralysis, and trigeminal neuralgia. * **EBV Association:** Types 2 and 3 are strongly associated with EBV (monitored via IgA anti-VCA titers). * **Treatment of Choice:** Radiotherapy (NPC is highly radiosensitive; surgery is technically difficult due to the anatomical location).

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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