Neck Masses Evaluation — MCQs
Which of the following carcinomas commonly presents with neck nodes?
The following statements about thyroglossal cyst are true, except:
Best imaging modality for acoustic neuroma screening
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 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?
Which of the following thyroid carcinomas cannot be definitively diagnosed by fine needle aspiration cytology (FNAC)?
Treatment of resectable T4N0M0 stage of head and neck carcinoma is?
Which of the following statements about Branchial cysts is true:
Which of the following statements is true about branchial cysts?
A middle-aged man presented with a swelling over the neck since childhood. The swelling is irregular and involves large nerves and their branches. Most probable diagnosis is:
Neck Masses Evaluation Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following carcinomas commonly presents with neck nodes?
- A. Cricoid
- B. Glottis
- C. Epiglottis (Correct Answer)
- D. Anterior commissure
Explanation: ***Epiglottis*** - Carcinomas of the epiglottis, a **supraglottic** structure, often present with neck node metastases due to a rich lymphatic drainage. - The **epiglottis** is considered a "silent area" for early symptoms, allowing tumors to grow and spread to regional lymph nodes before diagnosis. *Cricoid* - The cricoid cartilage is part of the **subglottic larynx**, and carcinomas in this region are rare and typically present later with **airway obstruction** rather than early neck nodes. - Subglottic cancers have a different lymphatic drainage pattern, often involving **paratracheal nodes** rather than the superficial neck nodes. *Glottis* - **Glottic carcinomas** (involving the true vocal cords) typically have an excellent prognosis because they present early with **hoarseness** due to interference with vocal cord vibration. - The glottis has a **sparse lymphatic supply**, meaning that neck node involvement is rare, especially in early stages. *Anterior commissure* - Carcinomas involving the **anterior commissure** are still considered part of the glottic region, and like other glottic cancers, they present with early **hoarseness**. - The lymphatic drainage of the anterior commissure is generally sparse, leading to a **low incidence of early cervical lymph node metastases**.
Question 2: The following statements about thyroglossal cyst are true, except:
- A. Frequent cause of anterior midline neck masses in the first decade of life
- B. The swelling moves upwards on protrusion of tongue
- C. The cyst is located within 2 cm of the midline
- D. Incision and drainage is the treatment of choice (Correct Answer)
Explanation: ***Incision and drainage is the treatment of choice*** - **Incision and drainage** is generally not the definitive treatment for a thyroglossal duct cyst due to the high risk of **recurrence**. - The standard surgical approach is the **Sistrunk procedure**, which involves excising the cyst, the mid-portion of the hyoid bone, and the tract up to the foramen cecum. *Frequent cause of anterior midline neck masses in the first decade of life* - **Thyroglossal duct cysts** are indeed the most common congenital neck masses, often presenting in childhood, particularly in the **first decade of life**. - They arise from the embryological remnant of the **thyroglossal duct**, which normally involutes. *The cyst is located within 2 cm of the midline* - **Thyroglossal cysts** are almost always found in the **midline** or slightly off-midline of the neck. - Their location is consistent with the path of the **descending thyroid gland** during embryonic development. *The swelling moves upwards on protrusion of tongue* - This is a classic diagnostic sign for a **thyroglossal duct cyst**. - The cyst is connected to the tongue via the **thyroglossal duct remnant**, so tongue protrusion causes the cyst to elevate.
Question 3: Best imaging modality for acoustic neuroma screening
- A. Nuclear scan
- B. CT temporal bone
- C. MRI with gadolinium (Correct Answer)
- D. Plain skull X-ray
Explanation: ***MRI with gadolinium*** - **Magnetic Resonance Imaging (MRI) with gadolinium contrast** is the gold standard for acoustic neuroma (vestibular schwannoma) detection due to its superior soft tissue resolution. - It effectively visualizes **small tumors** arising from the vestibular nerve within the internal auditory canal and cerebellopontine angle. *Nuclear scan* - **Nuclear scans** are generally used for assessing metabolic activity or specific tissue uptake, such as in oncology for metastasis detection or thyroid conditions. - They lack the **anatomical detail and resolution** needed to visualize small intracranial tumors like acoustic neuromas. *CT temporal bone* - **CT scans of the temporal bone** are excellent for evaluating bony structures, such as fractures or erosion of the internal auditory canal. - However, they have **limited sensitivity for soft tissue masses** and can miss small acoustic neuromas. *Plain skull X-ray* - **Plain skull X-rays** provide very limited information about soft tissues and are not useful for screening or diagnosing acoustic neuromas. - They mainly visualize **gross bony abnormalities** and cannot detect subtle pathologies within the internal auditory canal or cerebellopontine angle.
Question 4: 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 5: A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?
- A. Direct laryngoscopy with biopsy (Correct Answer)
- B. MRI of neck
- C. CT scan of neck
- D. Radiotherapy
Explanation: ***Direct laryngoscopy with biopsy*** - A definitive diagnosis of a vocal cord mass requires **histological examination** to rule out malignancy, especially given the patient's risk factors (age, smoking) and symptoms (hoarseness, dysphagia, weight loss). - **Direct laryngoscopy** allows for a thorough, magnified view of the mass and precise biopsy collection, which is superior to flexible laryngoscopy alone for definitive diagnosis and staging. *MRI of neck* - While MRI can provide excellent soft tissue detail for **staging** a known malignancy, it cannot provide a **histological diagnosis**. - It would typically be performed after a biopsy confirms malignancy to assess the extent of the tumor and potential spread. *CT scan of neck* - A CT scan is useful for evaluating **bony involvement**, lymph node status, and tumor extension for **staging purposes**, but it is not a diagnostic tool for identifying the specific type of tissue or cell pathology. - Like MRI, a CT scan would generally follow a biopsy confirming malignancy. *Radiotherapy* - **Radiotherapy** is a treatment modality for laryngeal cancer, not a diagnostic step. - Initiating treatment without a definitive histological diagnosis of malignancy would be inappropriate and potentially harmful.
Question 6: 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 7: Treatment of resectable T4N0M0 stage of head and neck carcinoma is?
- A. Radiotherapy alone
- B. Surgery and Radiotherapy (Correct Answer)
- C. Chemoradiation
- D. Surgery alone
Explanation: ***Surgery and Radiotherapy*** - For **resectable T4N0M0 head and neck carcinoma**, the standard treatment is **surgical resection** of the primary tumor followed by **adjuvant radiotherapy**. - This approach achieves optimal **local control** for advanced primary tumors without nodal involvement. - **Adjuvant radiotherapy** is essential for T4 tumors due to high risk of microscopic residual disease and local recurrence. - Surgery allows for complete tumor removal with negative margins, while radiotherapy addresses subclinical disease. *Radiotherapy alone* - Radiotherapy alone is **insufficient as monotherapy** for T4 tumors due to the large tumor burden and extensive local invasion. - Single modality radiation cannot reliably achieve adequate tumor control for advanced primary lesions. - Generally reserved for early-stage disease or patients unfit for surgery. *Chemoradiation* - **Definitive chemoradiation** is an alternative for **unresectable T4 tumors** or when organ preservation is desired (e.g., laryngeal cancer). - For **resectable** T4N0M0 disease, surgery with adjuvant RT is preferred as it provides better local control and allows pathological staging. - Chemoradiation may be used postoperatively if high-risk features are found (positive margins, perineural invasion, extranodal extension). - In this **N0 case with resectable tumor**, upfront surgery is the preferred initial approach. *Surgery alone* - While surgical resection is crucial for T4 tumors, **surgery alone is inadequate** due to high risk of locoregional recurrence. - T4 classification indicates extensive local invasion, necessitating **adjuvant radiotherapy** to eradicate microscopic disease. - Combined modality treatment (surgery + RT) significantly improves local control and survival compared to surgery alone.
Question 8: Which of the following statements about Branchial cysts is true:
- A. 50-70% are seen in lungs
- B. They are premalignant lesions
- C. Infection is uncommon in branchial cysts
- D. Most common site is lateral neck (Correct Answer)
Explanation: ***Most common site is lateral neck*** - **Branchial cleft cysts** typically present as a mass in the **lateral neck**, anterior to the sternocleidomastoid muscle. - They are congenital anomalies resulting from incomplete obliteration of the branchial clefts during embryonic development. *50-70% are seen in lungs* - This statement is incorrect; branchial cysts are **cervical anomalous masses** arising from the branchial apparatus, not primarily found in the lungs. - Lung lesions are more commonly associated with congenital pulmonary airway malformations or bronchogenic cysts, which differ in origin. *They are premalignant lesions* - Branchial cysts are generally **benign lesions** and do not typically transform into malignancy. - While rare cases of carcinoma arising within a branchial cleft cyst have been reported, they are not considered routinely premalignant. *Infection is uncommon in branchial cysts* - Conversely, infection is a **common complication** of branchial cysts, often leading to sudden enlargement, pain, and erythema. - The presence of internal fluid and epithelial lining makes them susceptible to bacterial colonization and subsequent abscess formation.
Question 9: Which of the following statements is true about branchial cysts?
- A. Branchial cysts are more common in males than females.
- B. They mostly arise from the second branchial cleft. (Correct Answer)
- C. Surgical intervention is not always necessary.
- D. They can cause dysphagia and hoarseness if infected.
Explanation: ***They mostly arise from the second branchial cleft.*** - **Second branchial cleft cysts** are the most common type, accounting for approximately **95%** of all branchial anomalies. - They typically present as a smooth, fluctuant mass along the **anterior border of the sternocleidomastoid muscle** at the junction of the upper and middle third of the neck. - These cysts result from **incomplete obliteration** of the second branchial cleft during embryonic development. *Branchial cysts are more common in males than females.* - Branchial cysts have **no significant sex predilection**, affecting males and females with roughly equal frequency. - The overall incidence is relatively rare, with most cases presenting in late childhood or early adulthood. *Surgical intervention is not always necessary.* - **Complete surgical excision** is the **definitive treatment** and is strongly recommended for all branchial cysts. - Indications for surgery include: prevention of **recurrent infections**, risk of **abscess formation**, elimination of cosmetic concerns, and removal due to potential (though rare) **malignant transformation**. - While very small asymptomatic cysts may occasionally be observed, this carries significant risk of future complications, making surgery the standard of care in clinical practice. *They can cause dysphagia and hoarseness if infected.* - While an **infected branchial cyst** causes local inflammatory signs (pain, swelling, warmth, erythema), it **rarely causes dysphagia or hoarseness** unless exceptionally large. - These symptoms would require the cyst to compress the **pharynx** (dysphagia) or involve the **recurrent laryngeal nerve** (hoarseness), which is uncommon even with infection. - The primary presentation of infected cysts includes **tender neck mass** with overlying skin changes and possible **abscess formation**.
Question 10: A middle-aged man presented with a swelling over the neck since childhood. The swelling is irregular and involves large nerves and their branches. Most probable diagnosis is:
- A. Toxic nodular goitre
- B. Plexiform neurofibroma (Correct Answer)
- C. Lymphangioma
- D. Vasculitis
Explanation: ***Plexiform neurofibroma*** - This condition presents as an **irregular swelling** evident since childhood, which is characteristic of the slow growth associated with **plexiform neurofibromas**. - Its involvement of **large nerves and their branches** is a hallmark feature, distinguishing it from other neck masses. *Toxic nodular goitre* - This would present primarily as a **thyroid swelling** and is typically associated with symptoms of **hyperthyroidism**, which are not mentioned. - It does not involve **peripheral nerves** in the manner described. *Lymphangioma* - Lymphangiomas are **benign lymphatic malformations** that typically present as soft, compressible masses. - While they can occur in the neck and be present from childhood, they do not specifically involve or originate from **nerve branches**. *Vasculitis* - Vasculitis is an **inflammation of blood vessels**, which can cause a variety of symptoms including pain, skin lesions, and organ dysfunction. - It does not present as a localized, irregular neck swelling involving **nerve branches** with a history since childhood.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free