Neck Masses: Differential Diagnosis — MCQs

10 questions

Regarding parotid neoplasms, the false statement is

A 23-year-old male patient presents with midline swelling in the neck. The swelling moves with deglutition and protrusion of the tongue. What is the likely diagnosis?

A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?

Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?

Lymph node metastasis in neck is almost never seen with:

38 year old male underwent a tooth extraction at a local dental camp. After few days he develops fever and trismus. On local examination, there is a swelling at the angle of jaw . He has a poor oral hygiene and tonsils were pushed medially .No membranous covering or discharging sinus were seen around tonsils. Most likely diagnosis in this condition would be ?

Which of the following statements about Ludwig's angina is true?

Mark the false statement regarding Hürthle cell carcinoma:

Common differential diagnosis of verrucous carcinoma is -

Q10

Regarding choledochal cysts following features are true except:

Neck Masses: Differential Diagnosis Indian Medical PG Practice Questions and MCQs

Question 1: Regarding parotid neoplasms, the false statement is

A. FNA has low sensitivity and specificity in diagnosing parotid neoplasms (Correct Answer)
B. Enucleation leads to recurrence
C. Pain may be a pointer for malignancy
D. Deep lobe tumors can present with trismus as early presentation

Explanation: ***FNA has low sensitivity and specificity in diagnosing parotid neoplasms*** - **Fine needle aspiration (FNA)** is actually a highly sensitive and specific diagnostic tool for evaluating parotid gland masses, typically achieving sensitivity and specificity rates of over 90%. - It helps in distinguishing between inflammatory, benign, and malignant lesions with good accuracy, guiding subsequent management. - **This is the FALSE statement** - FNA actually has HIGH sensitivity and specificity. *Deep lobe tumors can present with trismus as early presentation* - **Trismus** (difficulty opening the mouth) is associated with **deep lobe parotid tumors** or tumors that invade adjacent masticator muscles or the pterygoid plates. - Deep lobe tumors can cause trismus when they extend toward or compress the muscles of mastication. - **This is a TRUE statement** - deep lobe involvement can cause trismus. *Enucleation leads to recurrence* - **Enucleation**, which involves simply shelling out the tumor without a cuff of healthy tissue, is associated with a significantly higher recurrence rate for benign parotid tumors, especially **pleomorphic adenomas** (20-45% recurrence). - The standard surgical approach for benign parotid tumors is **superficial parotidectomy** or partial parotidectomy to ensure clear margins and reduce recurrence. - **This is a TRUE statement** - enucleation does increase recurrence risk. *Pain may be a pointer for malignancy* - **Pain** associated with a parotid mass is a concerning symptom and often indicates **malignancy**, especially if it is persistent and progressive. - Benign parotid tumors are typically painless and slow-growing unless they become very large or inflamed. - **This is a TRUE statement** - pain is a red flag for malignancy.

Question 2: A 23-year-old male patient presents with midline swelling in the neck. The swelling moves with deglutition and protrusion of the tongue. What is the likely diagnosis?

A. Brachial cyst
B. Thyroglossal cyst (Correct Answer)
C. Plunging ranula
D. Dermoid cyst

Explanation: ***Thyroglossal cyst*** - A **thyroglossal cyst** is a congenital anomaly that arises from the persistent **thyroglossal duct**, a remnant of the thyroid's embryologic descent. - Its classic diagnostic feature is its movement with **deglutition** (due to attachment to the hyoid bone, which moves during swallowing) and **protrusion of the tongue** (as the thyroglossal duct is connected to the base of the tongue). *Brachial cyst* - A **brachial cyst** is a congenital neck mass that typically presents as a lateral neck swelling, often located along the anterior border of the **sternocleidomastoid muscle**. - Unlike a thyroglossal cyst, it does not typically move with **deglutition** or **tongue protrusion**. *Plunging ranula* - A **plunging ranula** is a type of mucocele that arises from the **sublingual gland** and extends below the mylohyoid muscle into the neck. - It presents as a cervical mass but is typically located in the floor of the mouth or submandibular region and does not move with **deglutition** or **tongue protrusion**. *Dermoid cyst* - A **dermoid cyst** is a congenital cyst that can occur anywhere on the body, including the head and neck, often presenting as a painless mass. - It arises from sequestered embryonic ectoderm and mesoderm, containing skin appendages, but it does not move with **deglutition** or **tongue protrusion**.

Question 3: A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?

A. 48%
B. 12%
C. 24%
D. 3% (Correct Answer)

Explanation: ***3%*** - **Purely cystic thyroid nodules** (as described in this case with "isolated cystic swelling") have a **very low risk of malignancy**, typically **2-3%** or less. - According to **ATA guidelines** and **TIRADS classification**, purely cystic nodules are considered **low suspicion** lesions. - The cystic nature suggests a **benign process** such as a degenerated adenoma, colloid cyst, or simple cyst. - **Fine needle aspiration (FNA)** may still be considered if the nodule is >2 cm or has any suspicious solid components, but is often not required for purely cystic lesions. *48%* - This percentage is **significantly higher** than the actual malignancy risk for a purely cystic thyroid swelling. - Such a **high risk** would typically be associated with **solid nodules** exhibiting highly suspicious ultrasound features such as: - Microcalcifications - Irregular or spiculated margins - Taller-than-wide shape - Marked hypoechogenicity - Extrathyroidal extension *24%* - This percentage represents a **moderate to high risk** of malignancy, which is **not characteristic** of an isolated purely cystic thyroid swelling. - A risk in this range might be seen with: - **Mixed solid-cystic nodules** with predominantly solid components - Solid nodules with **intermediate suspicious features** on ultrasound *12%* - While lower than 24% or 48%, 12% is still **considerably higher** than the generally accepted malignancy risk for purely cystic thyroid nodules. - This risk level could be plausible for: - **Predominantly cystic nodules** with some eccentric solid components - Solid nodules with **mildly suspicious** features on ultrasound

Question 4: Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?

A. Anaplastic carcinoma of thyroid
B. Medullary carcinoma of thyroid
C. Follicular carcinoma of thyroid (Correct Answer)
D. Papillary carcinoma of thyroid

Explanation: ***Follicular carcinoma of thyroid*** - The definitive diagnosis of **follicular carcinoma** requires the presence of **capsular or vascular invasion**, which cannot be assessed through **fine needle aspiration cytology (FNAC)** alone [1], [5]. - FNA may show features suggestive of follicular neoplasm (e.g., hypercellularity with microfollicles), but differentiation from **follicular adenoma** requires histological examination of the excised specimen [1], [4]. *Anaplastic carcinoma of thyroid* - **Anaplastic carcinoma** is highly aggressive and characterized by **pleomorphic, bizarre cells** that are easily identifiable on FNAC [2], [5]. - The distinctive cytological features, including **spindle cells, giant cells, and rapid cellular atypia**, allow for a relatively straightforward diagnosis via FNAC [2]. *Medullary carcinoma of thyroid* - **Medullary carcinoma** cells have characteristic cytological features, such as **plasmacytoid appearance**, **amyloid deposition**, and **neuroendocrine granules**, which can be identified on FNAC [5]. - Confirmation can be made by **immunohistochemical staining for calcitonin** on the FNA sample [5]. *Papillary carcinoma of thyroid* - **Papillary carcinoma** has distinct cytological features, including **orphan Annie eye nuclei**, **intranuclear grooves**, **pseudoinclusions**, and **papillary structures**, readily identified by FNAC [3]. - These features are highly specific and often allow for a definitive diagnosis of papillary thyroid carcinoma [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1101-1102. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 428-429. [5] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 430-431.

Question 5: Lymph node metastasis in neck is almost never seen with:

A. Carcinoma vocal cords (Correct Answer)
B. Supraglottic carcinoma
C. Carcinoma of tonsil
D. Papillary carcinoma thyroid

Explanation: ***Carcinoma vocal cords*** - The **vocal cords** are relatively poor in lymphatic drainage, which significantly reduces the likelihood of regional lymph node metastasis. - Due to this sparse lymphatic network, spread to cervical lymph nodes is rare, especially in early-stage disease. *Supraglottic carcinoma* - **Supraglottic** regions have a rich lymphatic network, leading to a high incidence of cervical lymph node metastasis, even in early stages. - Bilateral lymphatic drainage further increases the risk of nodal involvement. *Carcinoma of tonsil* - The **tonsils** are richly supplied with lymphatic vessels, making them prone to early and frequent metastasis to cervical lymph nodes. - Metastasis is often seen in levels II, III, and IV of the neck. *Papillary carcinoma thyroid* - **Papillary thyroid carcinoma** commonly metastasizes to regional lymph nodes, with documented rates as high as 30-80%. - Nodal metastasis can occur in the central compartment (level VI) and lateral neck (levels II-V).

Question 6: 38 year old male underwent a tooth extraction at a local dental camp. After few days he develops fever and trismus. On local examination, there is a swelling at the angle of jaw . He has a poor oral hygiene and tonsils were pushed medially .No membranous covering or discharging sinus were seen around tonsils. Most likely diagnosis in this condition would be ?

A. Ludwig's angina
B. Parapharyngeal abscess (Correct Answer)
C. Retropharyngeal abscess
D. Peritonsillar abscess

Explanation: ***Parapharyngeal abscess*** - The patient's history of a recent **tooth extraction** and poor oral hygiene, followed by fever, trismus, swelling at the angle of the jaw, and medially pushed tonsils, are classic symptoms of a **parapharyngeal abscess**. - This type of abscess develops in the **deep neck spaces** and can be caused by odontogenic infections, leading to significant swelling and potential airway compromise. *Ludwig's angina* - While also an odontogenic infection, **Ludwig's angina** primarily affects the **submandibular, sublingual, and submental spaces**, characterized by firm, brawny induration of the floor of the mouth and neck, with less prominent swelling at the angle of the jaw and often **tongue elevation**. - It does not typically present with the tonsils being pushed medially, as it involves spaces anterior to the tonsillar region. *Retropharyngeal abscess* - A **retropharyngeal abscess** typically presents with severe **dysphagia**, odynophagia, fever, and neck stiffness, often resulting from upper respiratory tract infections or trauma. - The swelling would be more prominent in the posterior pharyngeal wall, and would less commonly cause significant swelling at the angle of the jaw or trismus unless extensive. *Peritonsillar abscess* - A **peritonsillar abscess** usually develops due to a complication of tonsillitis, presenting with severe **sore throat**, unilateral tonsillar swelling, and a characteristic deviation of the **uvula** to the opposite side. - While tonsils are affected, they are not typically pushed *medially* from an external deep neck space infection in this manner, and swelling at the angle of the jaw is less pronounced.

Question 7: Which of the following statements about Ludwig's angina is true?

A. It is usually unilateral.
B. It spreads by lymphatics.
C. It is primarily a viral infection.
D. It involves both submandibular and sublingual spaces. (Correct Answer)

Explanation: ***It involves both submandibular and sublingual spaces.*** - Ludwig's angina is a rapidly spreading, **bilateral cellulitis** involving the **submandibular, sublingual, and submental spaces**. - Its involvement of these spaces can lead to a characteristic **"brawny" induration** of the neck and elevation of the tongue. - This is the defining anatomical characteristic of Ludwig's angina. *It is primarily a viral infection.* - Ludwig's angina is a **bacterial infection**, not viral. - The most common causative organisms are **oral flora**, including Streptococcus, Staphylococcus, and anaerobes. - **Dental infections** (particularly from the second and third mandibular molars) are the most common source (80-90% of cases). *It is usually unilateral.* - Ludwig's angina is characteristically a **bilateral infection** of the floor of the mouth and neck spaces. - Unilateral involvement would suggest a more localized infection, such as an **abscess**, rather than the diffuse cellulitis of Ludwig's angina. *It spreads by lymphatics.* - Ludwig's angina is a **diffuse cellulitis** that spreads via continuity through **fascial planes** and connective tissues, rather than primarily through the lymphatic system. - The absence of significant **lymphadenopathy** is a key differentiating feature from other neck infections.

Question 8: Mark the false statement regarding Hürthle cell carcinoma:

A. It can be diagnosed by FNAC. (Correct Answer)
B. Arises from Hürthle cells of the thyroid.
C. Central neck dissection is performed in certain cases.
D. It is not a variant of papillary thyroid cancer.

Explanation: ***It can be diagnosed by FNAC.*** - **Fine-needle aspiration cytology (FNAC)** alone cannot definitively diagnose Hürthle cell carcinoma because distinguishing between **benign Hürthle cell adenoma** and **malignant Hürthle cell carcinoma** requires evidence of **capsular or vascular invasion**, which cannot be assessed cytologically [1]. - FNAC results typically return as "**follicular neoplasm, Hürthle cell type**" or "**suspicious for Hürthle cell neoplasm**," necessitating surgical excision for definitive diagnosis [1]. *Arises from Hürthle cells of the thyroid.* - This statement is **true** because Hürthle cell carcinoma originates from **Hürthle cells** (also known as oxyphil cells or oncocytes), which are found in the thyroid gland. - These cells are characterized by abundant **eosinophilic, granular cytoplasm** due to a high concentration of mitochondria. *Central neck dissection is performed in certain cases.* - This statement is **true** because **central neck dissection** is considered in Hürthle cell carcinoma when there is evidence of **lymph node metastasis** or **high-risk disease features**. - While Hürthle cell carcinoma is less likely to metastasize to lymph nodes than papillary thyroid carcinoma, such an intervention may be necessary for staging and disease control. *It is not a variant of papillary thyroid cancer.* - This statement is **true** because Hürthle cell carcinoma is a distinct entity, classified as a variant of **follicular thyroid carcinoma**, not papillary thyroid carcinoma [1]. - It has a separate biological behavior and treatment strategy compared to papillary thyroid cancer. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1100-1101.

Question 9: Common differential diagnosis of verrucous carcinoma is -

A. Adenocarcinoma
B. Tuberculosis
C. Condylomata lata
D. Condylomata acuminata (Correct Answer)

Explanation: ***Condylomata acuminata*** - **Verrucous carcinoma** is a rare, well-differentiated squamous cell carcinoma that often presents as a large, exophytic, warty mass, making it clinically similar to **condylomata acuminata (genital warts)** [1]. - Both conditions can appear as **cauliflower-like lesions** on mucosal surfaces, especially in the anogenital region, necessitating **biopsy** for definitive differentiation [1]. *Adenocarcinoma* - **Adenocarcinoma** typically arises from glandular tissue and presents as a mass or ulcer, but rarely as a **verrucous (warty)** lesion [2]. - Its histological features, characterized by **glandular differentiation**, are distinct from the acanthotic, hyperkeratotic pattern of verrucous carcinoma [2]. *Tuberculosis* - **Tuberculosis** can cause granulomatous lesions, but these are typically **ulcerative** or **nodular**, rather than large, exophytic, warty growths characteristic of verrucous carcinoma. - Diagnosis involves identifying **acid-fast bacilli** and characteristic granulomas with caseous necrosis, which are absent in verrucous carcinoma. *Condylomata lata* - **Condylomata lata** are broad, flat, moist papules associated with **secondary syphilis**, which are distinct from the exophytic, warty appearance of verrucous carcinoma [3]. - These lesions are typically **non-pruritic** and reveal spirochetes on dark-field microscopy, unlike verrucous carcinoma [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 974-975. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lower Urinary Tract and Male Genital System, pp. 973-974. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1000-1002.

Question 10: Regarding choledochal cysts following features are true except:

A. Older presentations have an acquired variant (Correct Answer)
B. Increased risk of cholangiocarcinoma in older presentations
C. Congenital cysts
D. 60% are diagnosed before 10 years

Explanation: **_Older presentations have an acquired variant_** - Choledochal cysts are universally considered **congenital anomalies** due to an anomalous pancreaticobiliary junction, even if presenting later in life. They are not typically classified into acquired and congenital variants. - While some theories suggest a role for acquired inflammation or obstruction in their development or progression, the underlying predisposition is congenital. *Increased risk of cholangiocarcinoma in older presentations* - The risk of **cholangiocarcinoma** is significantly elevated in patients with choledochal cysts, and this risk increases with age. - Prophylactic excision is recommended due to this malignant potential, particularly in older individuals. *Congenital cysts* - Choledochal cysts are indeed **congenital malformations** of the bile ducts, characterized by cystic dilation of any part of the biliary tree. - The fundamental defect is believed to be an **anomalous pancreaticobiliary junction (APBJ)**, leading to reflux of pancreatic enzymes into the bile duct. *60% are diagnosed before 10 years* - A significant proportion of choledochal cysts are diagnosed in **childhood**, with approximately 60% of cases identified before the age of 10 years. - However, around 20% of cases are diagnosed in adulthood, often presenting with complications.

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