ENT Oncology — MCQs
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A 49-year-old female from Nagaland presented with right-sided hearing loss and tinnitus. On examination, dull tympanic membrane with lymph nodes in the posterior triangle of the neck was seen. Which of the following is the management for the condition?
Which of the following is incorrect regarding Juvenile Nasopharyngeal Angiofibroma (JNA)?
A 72-year-old female smoker presents with a long history of hoarseness and difficulty swallowing. Laryngoscopy and biopsy confirm a large, advanced squamous cell carcinoma that involves both vocal cords and extends into the subglottic region and the thyroid cartilage. The tumor is not amenable to radiation therapy alone. Based on the extent and location of the tumor, which of the following surgical procedures is most appropriate to ensure complete tumor removal with adequate margins and control the disease?
Which of the following statements regarding Juvenile Nasopharyngeal Angiofibroma (JNA) is NOT typically correct or recommended?
A 60-year-old male presents with painless cervical lymphadenopathy. On examination, the right ear reveals conductive hearing loss with a dull tympanic membrane. Moreover, decreased mobility of the soft palate was also noted. What is the probable diagnosis?
Most common malignancy of maxillary antrum:
A person presents with neck node and B type tympanogram. What is the most likely diagnosis?
Most common site for nasopharyngeal carcinoma is:
Juvenile nasopharyngeal angiofibroma spreading to pterygomaxillary fossa is which stage?
True about Trotter's triad - a) Conductive deafness b) Involvement of CN VI c) Involvement of CN X d) Palatal paralysis e) Associated with nasopharyngeal angiofibroma
ENT Oncology Indian Medical PG Practice Questions and MCQs
Question 101: A 49-year-old female from Nagaland presented with right-sided hearing loss and tinnitus. On examination, dull tympanic membrane with lymph nodes in the posterior triangle of the neck was seen. Which of the following is the management for the condition?
- A. Grommet insertion + Steroids
- B. Steroids
- C. Radiotherapy (Correct Answer)
- D. Grommet insertion
Explanation: ***Correct: Radiotherapy*** - This clinical presentation is **classic for nasopharyngeal carcinoma (NPC)**: middle-aged patient from **Nagaland** (endemic region for NPC in Northeast India), unilateral serous otitis media (dull TM, hearing loss, tinnitus from Eustachian tube obstruction), and **posterior triangle lymphadenopathy** (most characteristic feature) - **NPC is highly radiosensitive** and radiotherapy is the primary treatment modality for all stages - Concurrent chemoradiotherapy is the standard for locally advanced disease - The geographic origin (Nagaland) is a critical clue as NPC has high incidence in Northeast India, Southeast Asia, and Southern China (associated with EBV infection and dietary factors) *Incorrect: Grommet insertion + Steroids* - Treats only the **secondary middle ear effusion**, not the underlying malignancy - Would delay definitive diagnosis and treatment of NPC - May temporarily relieve hearing symptoms but doesn't address the cancer *Incorrect: Steroids* - No role in the treatment of nasopharyngeal carcinoma - May mask symptoms and delay diagnosis - Does not address the underlying malignancy or lymphadenopathy *Incorrect: Grommet insertion* - Only addresses the **symptomatic serous otitis media**, not the primary pathology - The presence of posterior triangle lymph nodes makes malignancy the priority - Any adult with unilateral serous otitis media + cervical lymphadenopathy requires nasopharyngoscopy and biopsy to rule out NPC before symptomatic treatment
Question 102: Which of the following is incorrect regarding Juvenile Nasopharyngeal Angiofibroma (JNA)?
- A. Biopsy is contraindicated
- B. Epistaxis is the most common presenting symptom
- C. Unilateral cervical lymph nodes are a common feature (Correct Answer)
- D. Only seen in young boys
Explanation: ### **Explanation: Juvenile Nasopharyngeal Angiofibroma (JNA)** **Juvenile Nasopharyngeal Angiofibroma (JNA)** is a benign but locally aggressive, highly vascular tumor. #### **Why Option C is Incorrect (The Correct Answer)** * **JNA is a benign tumor:** By definition, benign tumors do not metastasize. Therefore, **cervical lymphadenopathy is NOT a feature** of JNA. * If a young male presents with a nasopharyngeal mass and cervical lymphadenopathy, the clinician should suspect **Nasopharyngeal Carcinoma (NPC)** or Lymphoma instead. #### **Analysis of Other Options** * **A. Biopsy is contraindicated:** Because the tumor is composed of thin-walled blood vessels lacking a muscular coat (*tunica media*), it is prone to **profuse, life-threatening hemorrhage**. Diagnosis is made clinically and via imaging (CT/MRI); biopsy is strictly avoided unless done in an operating room under extreme caution. * **B. Epistaxis is the most common symptom:** The classic presentation is a triad of **painless, progressive nasal obstruction**, **recurrent profuse epistaxis**, and a mass in the nasopharynx. * **D. Only seen in young boys:** JNA is an **androgen-dependent** tumor seen almost exclusively in adolescent males (typically ages 10–20). If seen in a female, genetic testing (karyotyping) is often recommended. --- ### **High-Yield Clinical Pearls for NEET-PG/INI-CET** * **Origin:** Most commonly from the superior border of the **sphenopalatine foramen**. * **Holman-Miller Sign (Antral Sign):** A pathognomonic radiological finding on CT showing **anterior bowing of the posterior wall of the maxillary sinus**. * **Frog-Face Deformity:** Occurs due to the widening of the nasal bridge and proptosis in advanced stages. * **Investigation of Choice:** **Contrast-Enhanced CT (CECT)** to assess bony involvement; **Angiography** is done to identify the feeding vessel (usually the **Internal Maxillary Artery**) and for preoperative embolization. * **Treatment:** Surgical excision (e.g., Transpalatal, Maxillary swing, or Endoscopic approach) preceded by **preoperative embolization** to reduce blood loss.
Question 103: A 72-year-old female smoker presents with a long history of hoarseness and difficulty swallowing. Laryngoscopy and biopsy confirm a large, advanced squamous cell carcinoma that involves both vocal cords and extends into the subglottic region and the thyroid cartilage. The tumor is not amenable to radiation therapy alone. Based on the extent and location of the tumor, which of the following surgical procedures is most appropriate to ensure complete tumor removal with adequate margins and control the disease?
- A. Emergency tracheostomy
- B. Submental tracheostomy
- C. Partial laryngectomy
- D. Total laryngectomy (Correct Answer)
Explanation: ***Total laryngectomy*** - This procedure is the standard of care for **advanced laryngeal carcinoma (T3/T4a)** when there is extensive involvement, including the **thyroid cartilage invasion** and extension into the **subglottic region**. - Given the tumor's size, bilateral cord involvement, and lack of response to primary radiation, total laryngectomy is required to achieve complete tumor removal with **negative surgical margins**. *Partial laryngectomy* - This technique is generally restricted to **early-stage tumors (T1 or T2)** confined to one part of the larynx without substantial cartilage or subglottic spread. - Attempting a partial resection on a large, bilateral tumor with **cartilage invasion** would result in positive margins and an unacceptable risk of local recurrence. *Emergency tracheostomy* - This is a procedure performed solely to relieve **acute airway obstruction**, which may occur in advanced laryngeal cancer, but it is not a curative treatment for the malignancy itself. - It addresses the symptom (airway compromise) but fails to remove the **squamous cell carcinoma** that is threatening the patient's life. *Submental tracheostomy* - A tracheostomy is an airway management procedure, not a definitive oncologic surgery for removing a large laryngeal tumor. - A standard tracheostomy (for airway placement) is sometimes needed, but placing it specifically in the **submental region** is not the standard location for a permanent tracheostoma following curative total laryngectomy.
Question 104: Which of the following statements regarding Juvenile Nasopharyngeal Angiofibroma (JNA) is NOT typically correct or recommended?
- A. Recurrent epistaxis
- B. Unilateral nasal obstruction
- C. Exclusively to adolescent boys
- D. Biopsy under anesthesia to diagnose (Correct Answer)
Explanation: ### **Explanation: Juvenile Nasopharyngeal Angiofibroma (JNA)** **Juvenile Nasopharyngeal Angiofibroma (JNA)** is a benign but locally aggressive, highly vascular tumor. Understanding its management is crucial for NEET-PG/INI-CET. #### **Why "Biopsy" is the Correct Answer (The Incorrect Practice)** * **Contraindication:** A biopsy is **strictly contraindicated** in suspected cases of JNA. Because the tumor is composed of thin-walled blood vessels lacking a muscular coat (*tunica media*), it cannot constrict when injured. * **Risk:** Performing a biopsy can trigger **profuse, life-threatening hemorrhage** that is difficult to control. * **Diagnosis:** Diagnosis is primarily **clinical and radiological**. Contrast-enhanced CT (CECT) or MRI showing the characteristic "Holman-Miller Sign" is sufficient to proceed to surgery without a tissue diagnosis. #### **Analysis of Other Options** * **A & B (Recurrent Epistaxis & Unilateral Nasal Obstruction):** These are the **classic clinical dyad** of JNA. Epistaxis is typically spontaneous, painless, and recurrent. Obstruction is initially unilateral but can become bilateral as the tumor grows. * **C (Exclusively to Adolescent Boys):** JNA is a **testosterone-dependent** tumor. It occurs almost exclusively in males, typically between **10–20 years of age**. If a similar mass is found in a female, a chromosomal analysis or alternative diagnosis should be considered. --- ### **High-Yield Clinical Pearls for INI-CET** * **Origin:** Most commonly arises from the superior border of the **sphenopalatine foramen**. * **Holman-Miller Sign (Antral Sign):** Forward bowing of the posterior wall of the maxillary sinus seen on CT. * **Frog Face Deformity:** Occurs due to the widening of the nasal bridge and proptosis in advanced stages. * **Investigation of Choice:** **CECT** (to assess bone involvement) or **MRI** (to assess intracranial extension). * **Gold Standard Treatment:** Surgical excision (usually via endoscopic or open approaches). **Pre-operative embolization** (24–48 hours prior) is done to reduce intraoperative blood loss. * **Classification:** Fisch or Radkowski classifications are commonly used to stage the tumor.
Question 105: A 60-year-old male presents with painless cervical lymphadenopathy. On examination, the right ear reveals conductive hearing loss with a dull tympanic membrane. Moreover, decreased mobility of the soft palate was also noted. What is the probable diagnosis?
- A. Adenoid cystic cancer
- B. Nasopharyngeal carcinoma (Correct Answer)
- C. Juvenile nasopharyngeal angiofibroma
- D. Quinsy
Explanation: ***Nasopharyngeal carcinoma*** - This presentation with **painless cervical lymphadenopathy**, **conductive hearing loss** due to Eustachian tube obstruction, and **cranial nerve involvement** (affecting the soft palate mobility) is highly suggestive of nasopharyngeal carcinoma, which often metastasizes early. - The conductive hearing loss, specifically a **dull tympanic membrane**, points to **otitis media with effusion** secondary to Eustachian tube dysfunction, a common presentation of nasopharyngeal masses obstructing the tube. *Adenoid cystic cancer* - While adenoid cystic carcinoma can cause cranial nerve palsies due to **perineural invasion**, it more commonly arises in the salivary glands and not typically presents with nasopharyngeal masses causing Eustachian tube obstruction. - It usually presents with a **palpable mass** or **pain**, which is not the primary presentation here. *Juvenile nasopharyngeal angiofibroma* - This is a **benign vascular tumor** typically presenting in **adolescent males** with episodes of **severe epistaxis** and **nasal obstruction**. - It does not commonly present with cervical lymphadenopathy or cranial nerve involvement and is rare in a 60-year-old. *Quinsy* - Quinsy, or **peritonsillar abscess**, presents acutely with **severe sore throat**, **fever**, **trismus**, and sometimes **uvular deviation**. - It is an **infectious condition** and does not typically cause painless cervical lymphadenopathy or conductive hearing loss as described.
Question 106: Most common malignancy of maxillary antrum:
- A. Muco-epidermoid Carcinoma
- B. Adenoid cystic Carcinoma
- C. Adenocarcinoma
- D. Squamous cell Carcinoma (Correct Answer)
Explanation: ***Squamous cell Carcinoma*** - **Squamous cell carcinoma (SCC)** accounts for approximately **80% of all malignant tumors** of the maxillary antrum. - This prevalence is due to the **squamous metaplasia** of the respiratory epithelium lining the sinus, especially in response to chronic irritation or inflammation. *Mucoepidermoid Carcinoma* - While it can occur in the maxillary sinus, **mucoepidermoid carcinoma** is a rare tumor, typically arising from **minor salivary glands**. - It is far **less common** than squamous cell carcinoma in the maxillary antrum. *Adenoid cystic Carcinoma* - **Adenoid cystic carcinoma** is a relatively rare tumor that more commonly affects the **major and minor salivary glands** and is known for its **perineural invasion** and slow growth, but it is not the most common in the maxillary antrum. - Its presence in the maxillary sinus is usually an **extension from adjacent structures** or a primary tumor of minor salivary glands within the sinus. *Adenocarcinoma* - **Adenocarcinoma** of the maxillary antrum is less common than SCC, often associated with exposure to **wood dust** or **leather processing**. - It typically arises from **seromucinous glands** within the sinus lining, but its incidence is significantly lower than that of squamous cell carcinoma.
Question 107: A person presents with neck node and B type tympanogram. What is the most likely diagnosis?
- A. Acoustic neuroma
- B. Nasopharyngeal CA (Correct Answer)
- C. None of the options
- D. Angiofibroma
Explanation: ***Nasopharyngeal CA*** - A **neck node** can be a presenting symptom of **nasopharyngeal carcinoma (NPC)** due to metastatic spread to cervical lymph nodes, often as the first presenting feature in ~75% of cases. - A **Type B tympanogram** indicates reduced compliance of the tympanic membrane, often due to **otitis media with effusion (OME)**, which can be caused by Eustachian tube obstruction from a nasopharyngeal mass like NPC. - This is the **classic presentation** combining lymphadenopathy with conductive hearing loss/middle ear effusion. *Acoustic neuroma* - An **acoustic neuroma** (vestibular schwannoma) typically presents with **unilateral sensorineural hearing loss**, tinnitus, and balance issues. - It does not directly cause an obstructive process leading to a Type B tympanogram or cervical lymphadenopathy. - Metastasis from acoustic neuroma is extremely rare. *Angiofibroma* - **Angiofibroma** is a benign, highly vascular tumor typically found in the **nasopharynx**, primarily affecting adolescent males. - While it can cause **nasal obstruction** and epistaxis, leading to Eustachian tube dysfunction and a Type B tympanogram, it is **benign and does not metastasize** to neck nodes. - This is a key differentiating feature from nasopharyngeal carcinoma.
Question 108: Most common site for nasopharyngeal carcinoma is:
- A. Posterior end of septum
- B. Fossa of Rosenmuller (Correct Answer)
- C. Lateral part of nasopharynx
- D. Posterior part of nasal cavity close to the margin of sphenopalatine foramen
Explanation: ***Fossa of Rosenmuller*** - The **fossa of Rosenmuller**, also known as the pharyngeal recess, is the most common site for the development of **nasopharyngeal carcinoma (NPC)**. - This anatomical location is prone to tumor development due to its complex lymphatic drainage and potential exposure to environmental factors. *Post part of Nasal cavity close to the margin of sphenopalatine foramen* - While this area is part of the nasopharynx, it is not the **predominant site** for the origin of **nasopharyngeal carcinoma (NPC)**. - Tumors originating here would be less common than those in the fossa of Rosenmuller. *Post end of septum* - The posterior end of the nasal septum is an anatomical structure in the nasopharynx but is **not a common primary site** for **nasopharyngeal carcinoma**. - Tumors are more likely to arise from the lateral walls or roof of the nasopharynx. *Lateral part of nasopharynx* - The lateral part of the nasopharynx is a general description, and while the **fossa of Rosenmuller** is located on the lateral wall, it is a **more specific and common site** for NPC. - Simply stating "lateral part" is less precise than identifying the fossa of Rosenmuller.
Question 109: Juvenile nasopharyngeal angiofibroma spreading to pterygomaxillary fossa is which stage?
- A. Stage IV
- B. Stage III
- C. Stage II (Correct Answer)
- D. Stage I
Explanation: ***Stage II*** - This stage describes **tumor extension** to the **pterygomaxillary fossa** or maxillary, ethmoid, or sphenoid sinuses with bone destruction. - According to the **Fisch staging system** (most widely used), pterygomaxillary fossa involvement specifically defines Stage II disease. - This represents locally advanced disease beyond the nasopharynx but without infratemporal fossa or intracranial extension. *Stage III* - This stage signifies extension to the **infratemporal fossa**, **orbit**, or **parasellar region** (remaining lateral to cavernous sinus). - It represents more extensive local spread than pterygomaxillary fossa involvement alone. - Requires more complex surgical approaches and has greater morbidity. *Stage IV* - This stage indicates **intracranial extension** with involvement of the **cavernous sinus**, **optic chiasm**, or **pituitary fossa**. - It represents the most advanced disease with the highest surgical complexity and potential for complications. - Often requires combined neurosurgical approaches. *Stage I* - Stage I describes a tumor strictly confined to the **nasopharynx** and **nasal cavity** without extension to adjacent structures. - This is the earliest stage with the best prognosis and typically amenable to endoscopic resection. - No bone destruction or extension to sinuses or fossae.
Question 110: True about Trotter's triad - a) Conductive deafness b) Involvement of CN VI c) Involvement of CN X d) Palatal paralysis e) Associated with nasopharyngeal angiofibroma
- A. bde
- B. bc
- C. acd (Correct Answer)
- D. ad
Explanation: ***acd*** - Trotter's triad consists of **conductive deafness** (option a) due to Eustachian tube obstruction, **ipsilateral trigeminal neuralgia** (CN V involvement), and **soft palate paralysis** (option d) caused by tumor infiltration. - Option c refers to **CN X (vagus nerve) involvement**, which can contribute to palatal paralysis, making it part of the clinical presentation. - The combination of **conductive deafness**, **CN X involvement** causing palatal issues, and **palatal paralysis** are correct components of Trotter's triad. - This triad is classically associated with **nasopharyngeal carcinoma**. *Incorrect Option: bde* - This option incorrectly includes CN VI involvement (abducens nerve), which is **not part of Trotter's triad**. - It also incorrectly associates the triad with **nasopharyngeal angiofibroma** rather than carcinoma. - While option d (palatal paralysis) is correct, the combination is incorrect due to options b and e. *Incorrect Option: bc* - Option b refers to **CN VI (abducens nerve) involvement**, which is **not part of the classic Trotter's triad**. - The triad involves **CN V (trigeminal)** for neuralgia, not CN VI. - While CN X involvement (option c) can be present, this combination misses the essential conductive deafness and includes the wrong cranial nerve. *Incorrect Option: ad* - This option correctly includes **conductive deafness** (a) and **palatal paralysis** (d). - However, it **misses option c (CN X involvement)**, which is important for explaining the mechanism of palatal paralysis. - While partially correct, it's incomplete compared to option acd.
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