ENT Oncology — MCQs

ENT Oncology Indian Medical PG Practice Questions and MCQs

Question 81: Which site of squamous cell carcinoma has the best prognosis?

A. Lip (Correct Answer)
B. Tongue
C. Palate
D. Floor of the mouth

Explanation: **Explanation:** The prognosis of Squamous Cell Carcinoma (SCC) in the oral cavity is primarily determined by the site's lymphatic drainage, the thickness of the lesion, and the ease of early detection. **Why Lip is the correct answer:** Carcinoma of the lip (specifically the lower lip) has the **best prognosis** among all oral cavity cancers. This is due to several factors: 1. **Early Detection:** Lesions are highly visible, leading patients to seek medical advice early. 2. **Slow Growth:** Lip SCC tends to be well-differentiated and grows slowly. 3. **Limited Lymphatic Spread:** Lymphatic metastasis occurs late. The 5-year survival rate for lip SCC is often greater than 90%. **Analysis of Incorrect Options:** * **Tongue:** This is the most common site for oral SCC but carries a **poor prognosis** due to its rich lymphatic network and constant muscular activity, which facilitates early bilateral spread to deep cervical nodes. * **Floor of the Mouth:** This site has a high risk of early nodal metastasis (submandibular nodes) because the mucosa is thin and closely related to the underlying periosteum and lymphatics. * **Palate:** While hard palate SCC is less common, it often presents at a later stage than lip cancer and can invade the maxillary sinus or palatal bone, worsening the prognosis compared to the lip. **Clinical Pearls for NEET-PG:** * **Most common site of Oral Cavity Cancer:** Tongue (lateral border). * **Most common site of Lip Cancer:** Lower lip (due to UV exposure); Upper lip cancer is rarer but more aggressive. * **Field Cancerization:** This concept (by Slaughter et al.) explains why patients with one oral SCC are at high risk for synchronous or metachronous primary tumors. * **TNM Staging:** For oral SCC, **Depth of Invasion (DOI)** is now a critical component in T-staging (AJCC 8th Edition).

Question 82: Woodworkers are associated with which type of sinus carcinoma?

A. Adenocarcinoma (Correct Answer)
B. Squamous cell carcinoma
C. Anaplastic carcinoma
D. Melanoma

Explanation: **Explanation:** The correct answer is **Adenocarcinoma**. **1. Why Adenocarcinoma is correct:** There is a strong, well-documented epidemiological link between chronic exposure to **hardwood dust** (such as beech and oak) and the development of **Adenocarcinoma** of the ethmoid sinuses. Wood dust particles are thought to cause chronic mucosal irritation and contain specific chemical compounds that act as carcinogens. This is a classic occupational hazard question frequently tested in NEET-PG. **2. Why the other options are incorrect:** * **Squamous cell carcinoma (SCC):** While SCC is the **most common** overall histological type of paranasal sinus malignancy (accounting for ~80% of cases), it is more strongly associated with nickel exposure and smoking rather than wood dust specifically. It most commonly affects the maxillary sinus. * **Anaplastic carcinoma:** This is a rare, highly aggressive, and undifferentiated tumor. It does not have a specific association with woodworkers. * **Melanoma:** Sinonasal mucosal melanomas are rare and arise from melanocytes in the respiratory mucosa. Their etiology is largely unknown and not linked to occupational wood dust. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common site for Sinus Malignancy:** Maxillary Sinus. * **Most common site for Woodworker’s Adenocarcinoma:** Ethmoid Sinus. * **Nickel workers:** Associated with Squamous Cell Carcinoma. * **Leather/Footwear industry workers:** Also associated with Adenocarcinoma (similar to woodworkers). * **Ohngren’s line:** An imaginary line connecting the medial canthus to the angle of the mandible; tumors superior-posterior to this line have a poorer prognosis.

Question 83: Which of the following statements is NOT true regarding the hard palate?

A. It is typically painful. (Correct Answer)
B. Maxillectomy may be required for treatment.
C. Lymphatic spread is a possible complication.
D. Histologically, it can present as squamous cell carcinoma or adenocarcinoma.

Explanation: ### Explanation **1. Why Option A is the Correct Answer (The "Not True" Statement):** In ENT oncology, most early-stage malignant tumors of the hard palate are characteristically **painless**. They often present as an asymptomatic, slow-growing mass or an incidental finding during a dental examination. Pain is typically a late feature, occurring only when there is secondary infection, deep muscle infiltration, or perineural invasion (common in Adenoid Cystic Carcinoma). Therefore, saying it is "typically painful" is clinically inaccurate for initial presentations. **2. Analysis of Other Options:** * **Option B (Maxillectomy):** This is a standard surgical intervention. Depending on the extent of the tumor (T-stage), a partial, total, or extended maxillectomy is required to achieve clear surgical margins. * **Option C (Lymphatic Spread):** While the hard palate has a relatively sparse lymphatic network compared to the tongue or floor of the mouth, metastasis to the **level I and II cervical lymph nodes** is a recognized complication, especially in advanced squamous cell carcinoma. * **Option D (Histology):** The hard palate is unique because it contains both surface epithelium and numerous minor salivary glands. Thus, it can give rise to **Squamous Cell Carcinoma** (most common) or various **Minor Salivary Gland Tumors** (like Adenoid Cystic Carcinoma or Mucoepidermoid Carcinoma, often grouped under adenocarcinomas). **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common malignancy of the hard palate:** Squamous Cell Carcinoma. * **Most common minor salivary gland tumor of the hard palate:** Adenoid Cystic Carcinoma (known for **perineural invasion**). * **Risk Factors:** Reverse smoking (common in parts of India) is a high-yield risk factor specifically associated with hard palate cancer. * **Prosthetic Rehabilitation:** Post-maxillectomy, patients often require an **obturator** to seal the oronasal communication and restore speech and swallowing.

Question 84: Which of the following is NOT true for carcinoma of the tongue?

A. Lateral border is involved
B. Adenocarcinoma is the commonest type (Correct Answer)
C. Cervical lymph node involvement is common
D. Tobacco chewing is a significant risk factor

Explanation: **Explanation:** The correct answer is **B**, as **Squamous Cell Carcinoma (SCC)**—not adenocarcinoma—is the most common histological type of tongue cancer, accounting for over 90% of cases. Adenocarcinomas are rare and typically arise from minor salivary glands within the oral cavity. **Analysis of Options:** * **Option A (Lateral border):** This is the most frequent site for tongue carcinoma (especially the middle third). The dorsum is rarely involved, and the tip/ventral surface are less common. * **Option C (Lymph node involvement):** The tongue has a rich, decussating lymphatic network. Early lymphatic spread to the cervical nodes (specifically Level II/Jugulodigastric) is a hallmark of this disease, often occurring even in early stages. * **Option D (Tobacco chewing):** Chronic irritation from tobacco (chewing or smoking), betel nut, and alcohol are the primary synergistic risk factors for oral SCC. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Oral Cavity Cancer:** Lower lip (globally), but in India, it is the **buccal mucosa** (due to tobacco chewing). * **Premalignant lesions:** Leukoplakia (most common) and Erythroplakia (highest risk of transformation). * **Staging Tip:** Tongue cancers are staged based on size (T) and depth of invasion (DOI). A DOI > 5mm significantly increases the risk of nodal metastasis. * **Management:** Surgery is the primary treatment. For N0 necks, elective neck dissection is often performed if the tumor thickness exceeds 4mm.

Question 85: In which country is nasopharyngeal carcinoma most commonly found?

A. India
B. China (Correct Answer)
C. Pakistan
D. Japan

Explanation: **Explanation:** Nasopharyngeal Carcinoma (NPC) exhibits a unique geographical and ethnic distribution, making it a classic "high-yield" topic in ENT oncology. **1. Why China is Correct:** The highest incidence of NPC globally is found in **Southern China** (specifically the Guangdong province) and among Southeast Asian populations. This is attributed to a multifactorial etiology involving: * **Genetic Predisposition:** Specific HLA haplotypes (HLA-A2, B17, and Bw46) common in the Cantonese population. * **Dietary Factors:** High consumption of **salted fish** containing volatile nitrosamines, which are potent carcinogens. * **Viral Association:** A near 100% association with the **Epstein-Barr Virus (EBV)**, particularly in Type II and III (undifferentiated) WHO classifications. **2. Why other options are incorrect:** * **India:** While NPC occurs in India, it is primarily endemic only in the **North-Eastern states** (like Mizoram and Nagaland) due to dietary habits like smoked meats, but the national incidence does not rival China. * **Pakistan & Japan:** These countries have a low to intermediate incidence of NPC. Japan has a higher prevalence of gastric and esophageal cancers rather than nasopharyngeal. **Clinical Pearls for NEET-PG:** * **Most Common Site:** Fossa of Rosenmüller. * **Most Common Symptom:** Painless upper deep cervical lymphadenopathy (Level II/III). * **Trotter’s Triad:** 1. Conductive hearing loss (due to Eustachian tube blockage), 2. Ipsilateral palatal paralysis, 3. Trigeminal neuralgia (V2 involvement). * **Treatment of Choice:** Radiotherapy (it is highly radiosensitive); Surgery is usually reserved for salvage. * **Tumor Marker:** Plasma EBV DNA levels are used for screening and monitoring recurrence.

Question 86: Radiotherapy is used in the treatment of angiofibroma when it involves which of the following structures?

A. Cheek
B. Orbit
C. Middle cranial fossa (Correct Answer)
D. Cavernous sinus

Explanation: **Explanation:** Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign but locally aggressive, highly vascular tumor. The primary treatment of choice for JNA is **surgical excision** (typically via endoscopic or open approaches depending on the stage). **Why Middle Cranial Fossa is Correct:** Radiotherapy is generally reserved for **recurrent tumors** or **unresectable cases** where the tumor has invaded vital areas where surgery would carry an unacceptable risk of morbidity or mortality. Specifically, involvement of the **Middle Cranial Fossa** (intracranial extension) or the **Cavernous Sinus** are classic indications for radiotherapy. While the Cavernous Sinus is also a valid site for radiotherapy, in the context of standard ENT grading (like the Fisch or Radkowski classifications), extensive intracranial spread into the middle cranial fossa represents a critical threshold where surgery becomes high-risk, making radiotherapy the preferred modality to achieve local control. **Analysis of Incorrect Options:** * **A. Cheek:** Involvement of the cheek (infratemporal fossa/buccal space) is common in Stage II/III JNA and is managed surgically. * **B. Orbit:** Orbital involvement, while serious, is usually managed via surgical decompression and excision. * **D. Cavernous Sinus:** While radiotherapy is used here, "Middle Cranial Fossa" is often considered the broader, more definitive anatomical landmark for unresectable intracranial extension in standardized postgraduate questions. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Sphenopalatine foramen (specifically the posterior end of the middle turbinate). * **Classic Triad:** Adolescent male, profuse recurrent epistaxis, and nasal obstruction. * **Radiology Sign:** **Holman-Miller Sign** (antral sign) – anterior bowing of the posterior wall of the maxillary sinus. * **Pre-operative Step:** Embolization (24–48 hours prior) is mandatory to reduce intraoperative bleeding. * **Contraindication:** Biopsy is strictly contraindicated due to the risk of torrential hemorrhage.

Question 87: Mobility of teeth in carcinoma of the maxillary sinus is due to involvement by the tumor of which anatomical structure?

A. Anterior wall of the sinus
B. Posterior wall of the sinus
C. Roof of the sinus
D. Floor of the sinus (Correct Answer)

Explanation: **Explanation:** The clinical presentation of Maxillary Sinus Carcinoma depends on which wall of the sinus is breached by the tumor. The **floor of the maxillary sinus** is formed by the alveolar process of the maxilla and the hard palate. The roots of the upper molar and premolar teeth lie in close proximity to, or sometimes penetrate, this floor. When a tumor involves the **floor of the sinus**, it invades the alveolar bone and the periodontal ligaments. This destruction of the supporting dental architecture leads to **loosening/mobility of teeth**, dental pain, or unexplained swelling in the gingivolabial sulcus or palate. **Analysis of Incorrect Options:** * **Anterior Wall:** Involvement leads to swelling of the cheek and invasion of the facial soft tissues (infraorbital nerve involvement causes anesthesia of the cheek). * **Posterior Wall:** Involvement leads to invasion of the pterygopalatine fossa and infratemporal fossa, resulting in trismus (due to pterygoid muscle involvement) and referred earache. * **Roof:** The roof forms the floor of the orbit. Involvement leads to proptosis, diplopia, or displacement of the eyeball. **Clinical Pearls for NEET-PG:** * **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 than those located anteroinferiorly. * **Lederman’s Classification:** 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 (approx. 80%). * **Early Sign:** Most maxillary tumors are clinically silent; persistent unilateral "sinusitis" or blood-stained nasal discharge in an elderly patient should be investigated for malignancy.

Question 88: Which of the following are features of laryngeal carcinoma?

A. Glottis is the most common site
B. Commonly metastasizes to cervical lymph nodes
C. Lesions are seen at the edge of the vocal cord
D. Laryngeal compartments act as a barrier (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Laryngeal compartments act as a barrier.** The larynx is divided into distinct anatomical compartments (supraglottis, glottis, and subglottis) by fibro-elastic membranes, such as the **conus elasticus** and the **quadrangular membrane**. These membranes, along with the laryngeal cartilages (thyroid, cricoid), act as significant mechanical barriers that initially contain the spread of carcinoma within a specific compartment. This compartmentalization is a fundamental principle in laryngeal oncology, allowing for "Partial Laryngectomy" procedures where only the involved compartment is resected while preserving function. **Analysis of Incorrect Options:** * **A. Glottis is the most common site:** While glottic cancer is the most common site in the **Western world**, in the **Indian context** (highly relevant for NEET-PG), **Supraglottic carcinoma** is often reported as more frequent or equally common due to different tobacco-chewing habits. * **B. Commonly metastasizes to cervical lymph nodes:** This is true for supraglottic and subglottic cancers, but **Glottic cancer** (the most frequent type globally) has a very sparse lymphatic network. Therefore, glottic tumors rarely metastasize early, making this statement inaccurate as a general rule for all laryngeal carcinomas. * **C. Lesions are seen at the edge of the vocal cord:** While early glottic cancers often arise on the free edge of the anterior two-thirds of the vocal cord, laryngeal carcinoma as a whole can arise from any part of the laryngeal mucosa (e.g., epiglottis, aryepiglottic folds). **High-Yield Clinical Pearls for NEET-PG:** * **Hoarseness** is the earliest symptom of Glottic cancer. * **Stridor** is a late feature indicating airway compromise. * **Broyles’ Ligament:** The anterior commissure tendon; it lacks a perichondrium barrier, making it a weak point where glottic cancer can invade the thyroid cartilage. * **Most common histology:** Squamous Cell Carcinoma (>95%).

Question 89: What is the treatment of choice for laryngeal carcinoma of the glottis extending to the supraglottic region with vocal cord fixation and a palpable solitary ipsilateral lymph node?

A. Conservative laryngectomy
B. Total laryngectomy
C. Total laryngectomy with radical neck dissection (Correct Answer)
D. Palliative therapy

Explanation: ### Explanation The management of laryngeal carcinoma depends on the TNM staging, which is determined by the anatomical extent and nodal involvement. **1. Why Option C is Correct:** The clinical presentation indicates an advanced stage (Stage IV) laryngeal carcinoma: * **T-staging:** Extension from the glottis to the supraglottis with **vocal cord fixation** classifies this as at least a **T3 lesion**. * **N-staging:** The presence of a **palpable solitary ipsilateral lymph node** (likely N1) upgrades the clinical stage. For T3/T4 lesions with nodal involvement, the standard of care is **Total Laryngectomy** to ensure clear margins, combined with **Radical Neck Dissection** (or Modified Radical Neck Dissection) to address the metastatic cervical lymphadenopathy. **2. Why Other Options are Incorrect:** * **Option A (Conservative Laryngectomy):** This is reserved for early-stage (T1, T2) lesions where vocal cord mobility is preserved. It is contraindicated once the vocal cord is fixed. * **Option B (Total Laryngectomy alone):** While it addresses the primary tumor, it fails to address the palpable lymph node. In ENT oncology, "the neck must be treated" if there is clinical evidence of nodal spread. * **Option D (Palliative Therapy):** This is reserved for Stage IVB (unresectable) or Stage IVC (distant metastasis). This patient has a resectable T3N1 lesion, which is treated with curative intent. **Clinical Pearls for NEET-PG:** * **Vocal Cord Fixation:** Always signifies at least a **T3** lesion (due to invasion of the paraglottic space or cricoarytenoid joint). * **Most common site of Laryngeal Cancer:** Glottis (but it has the best prognosis due to sparse lymphatic drainage). * **Supraglottic Cancer:** Often presents late because it has a rich lymphatic network, leading to early bilateral nodal metastasis. * **Treatment of Choice for T1/T2:** Radiotherapy or Laser excision (organ preservation). * **Treatment of Choice for T3/T4:** Surgery (Total Laryngectomy) + Post-operative Radiotherapy.

Question 90: Which carcinoma most commonly metastasizes to cervical lymph nodes?

A. Maxillary sinus
B. Posterior tongue (Correct Answer)
C. Cheek
D. Hard palate

Explanation: **Explanation:** The frequency of cervical lymph node metastasis in head and neck cancers is primarily determined by the **richness of the lymphatic network** and the **mobility** of the primary site. **Why Posterior Tongue is Correct:** The posterior third of the tongue (base of tongue) is part of the oropharynx. It has an extremely rich, decussating (crossing) lymphatic drainage system. Approximately **70-80% of patients** with carcinoma of the posterior tongue present with clinically positive cervical nodes at the time of diagnosis, often bilateral. In contrast, the anterior two-thirds (oral tongue) has a lower rate (approx. 30-40%). **Analysis of Incorrect Options:** * **Maxillary Sinus:** These tumors are often "clinically silent" regarding nodes. Lymphatics from the antrum are sparse and primarily drain to the retropharyngeal nodes first, rather than the cervical chain. * **Cheek (Buccal Mucosa):** While it does metastasize to Level I and II nodes, the rate is significantly lower than the tongue, usually occurring in later stages. * **Hard Palate:** This area has a very sparse lymphatic network and the mucoperiosteum is tightly bound to bone, making lymphatic spread relatively uncommon and late. **NEET-PG High-Yield Pearls:** * **Most common site for distant metastasis in ENT:** Nasopharynx (due to rich lymphatics). * **N0 Neck:** Even if nodes are not palpable, posterior tongue and pyriform sinus cancers often require elective neck dissection/irradiation due to high rates of "occult" metastasis. * **Rouviere’s Node:** The most superior node of the lateral retropharyngeal group, often involved in Nasopharyngeal Carcinoma. * **Order of Metastatic Frequency:** Hypopharynx > Tongue Base > Tonsil > Oral Tongue.

Practice by Chapter

Staging of Head and Neck Cancer

Practice Questions

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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