ENT Oncology Practice Questions

Q: Factors that have been associated with an increased incidence of head and neck carcinomas include all of the following except?

Hepatitis B virus. **Explanation:** The correct answer is **Hepatitis B virus (HBV)**. While HBV is a major risk factor for hepatocellular carcinoma, it has no established causal link with head and neck squamous cell carcinomas (HNSCC). In contrast, other viruses like HPV (Oropharynx) and EBV (Nasopharynx) are strongly associated with head and neck oncology. **Analysis of Options:** * **Syphilis (Option A):** Historically, tertiary syphilis (specifically syphilitic glossitis) was a well-known risk factor for **carcinoma of the anterior two-thirds of the tongue**. Chronic inflammation and the use of arsenicals in older treatments contributed to this association. * **Exposure to Nickel (Option C):** Occupational exposure to heavy metals, particularly **nickel and chromium**, is a high-yield risk factor for **sinonasal adenocarcinoma** and squamous cell carcinoma of the nasal cavity and paranasal sinuses. * **Alcohol Consumption (Option D):** Alcohol acts synergistically with tobacco. It functions as a solvent, increasing the permeability of the oral mucosa to carcinogens, and its metabolite, acetaldehyde, is directly genotoxic. **High-Yield Clinical Pearls for NEET-PG:** 1. **Plummer-Vinson Syndrome:** Associated with an increased risk of post-cricoid carcinoma (Hypopharynx). 2. **Wood Dust Exposure:** Specifically linked to **Adenocarcinoma of the Ethmoid sinus**. 3. **EBV:** Strongly associated with **Nasopharyngeal Carcinoma** (Schmincke's tumor). 4. **HPV (Types 16 & 18):** Now the leading cause of **Oropharyngeal cancer** (especially tonsils and base of tongue) in non-smokers. 5. **Dietary Factors:** Vitamin A and C deficiencies are linked to increased HNSCC risk.

Q: What are the characteristic features of laryngeal carcinoma?

All of the above.. Laryngeal carcinoma, predominantly Squamous Cell Carcinoma (SCC), is a high-yield topic in ENT oncology. The correct answer is **D (All of the above)** because each option describes a fundamental clinical characteristic of the disease. **1. Glottis as the Most Common Site:** In most global populations (including India), the glottis (vocal cords) is the most common site for laryngeal cancer (approx. 60-65%), followed by the supraglottis. Glottic tumors often present early due to hoarseness of voice. **2. Cervical Lymph Node Metastasis:** While glottic cancers have sparse lymphatic drainage and rarely metastasize early, laryngeal cancer as a whole—specifically supraglottic and subglottic types—has a high propensity for spread to the deep cervical lymph nodes (Levels II, III, and IV). Supraglottic tumors often present with bilateral nodal involvement due to rich lymphatic networks. **3. Lesion Location:** Glottic lesions typically arise on the **free edge of the anterior two-thirds of the vocal cord**. This anatomical site is a transition zone for epithelium, making it susceptible to carcinogens like tobacco and alcohol. **High-Yield Clinical Pearls for NEET-PG:** * **Best Prognosis:** Glottic SCC (due to early symptoms and poor lymphatics). * **Worst Prognosis:** Subglottic SCC (often silent until advanced). * **Most Common Histology:** Keratinizing Squamous Cell Carcinoma. * **Staging Tip:** "Fixed vocal cord" automatically upgrades a tumor to **T3**. * **Treatment:** Early stages (T1, T2) are treated with radiotherapy or laser excision; advanced stages (T3, T4) usually require total laryngectomy.

Q: Which is the best prognosticator of survival from nasopharyngeal carcinoma?

WHO type III histology. **Explanation:** The prognosis of Nasopharyngeal Carcinoma (NPC) is heavily influenced by its histopathological subtype and its sensitivity to treatment. **Why WHO Type III is the correct answer:** The WHO classification divides NPC into three types: * **Type I:** Keratinizing squamous cell carcinoma. * **Type II:** Non-keratinizing differentiated carcinoma. * **Type III:** Undifferentiated carcinoma (including lymphoepithelioma). **WHO Type III** is the most common subtype and, despite its aggressive appearance, it has the **best prognosis**. This is because Type III tumors are highly **radiosensitive** and **chemosensitive**. They are also strongly associated with the Epstein-Barr Virus (EBV) and occur in younger age groups compared to Type I. **Analysis of Incorrect Options:** * **Option A (High angiogenesis):** While increased vascularity often correlates with tumor growth and potential for spread, it is a general pathological feature and not the primary prognosticator used in clinical practice for NPC. * **Option C (Lung metastases):** Distant metastasis (M1 stage) is a sign of advanced disease and indicates a **poor prognosis**, not the "best" prognosticator for survival. * **Option D (WHO Type I):** This subtype has the **worst prognosis**. It is least sensitive to radiotherapy, has a lower association with EBV, and is more common in older patients with a history of smoking/alcohol. **NEET-PG High-Yield Pearls:** * **Most common site:** Fossa of Rosenmüller. * **Most common symptom:** Painless upper deep cervical lymphadenopathy. * **Most common cranial nerve involved:** 6th CN (Abducens), leading to diplopia. * **Trotter’s Triad:** Conductive hearing loss (serous otitis media), palatal paralysis, and temporofacial neuralgia (5th CN involvement). * **Treatment of choice:** Radiotherapy (RT) is the primary modality; Chemoradiotherapy (CRT) for advanced stages. Surgery is reserved for salvage.

Q: Involvement of neck lymph nodes is seen in all the following conditions except?

Vocal cord carcinoma. The correct answer is **Vocal cord carcinoma** because of the unique lymphatic anatomy of the larynx. ### **1. Why Vocal Cord Carcinoma is the Correct Answer** The true vocal cords (glottis) are characterized by a **paucity of lymphatic drainage**. The epithelium is tightly bound to the underlying Reinke’s space, which lacks a well-developed lymphatic network. Consequently, early-stage glottic cancer (T1/T2) rarely metastasizes to the neck lymph nodes (incidence <1-2%). This is a high-yield clinical fact: patients with vocal cord cancer usually present early with hoarseness and have an excellent prognosis because the disease remains localized for a long duration. ### **2. Why the Other Options are Incorrect** * **Hodgkin’s Lymphoma:** Cervical lymphadenopathy is the most common presenting feature (seen in ~60-80% of cases). The nodes are typically firm, rubbery, and painless. * **Tumors of the Hypopharynx:** The hypopharynx has an extremely rich lymphatic network. Over 50-70% of patients present with palpable neck nodes (Level II, III, and IV) at the time of diagnosis. * **Nasopharyngeal Carcinoma:** This tumor is notorious for early lymphatic spread. In many cases, a neck mass (Level II or V) is the first clinical sign (Trottier’s triad). It has the highest incidence of bilateral nodal involvement among head and neck cancers. ### **3. NEET-PG High-Yield Pearls** * **Laryngeal Lymphatics:** The **Supraglottis** has the richest lymphatic drainage (Level II/III), while the **Glottis** has the least. * **Level of Nodes:** Nasopharyngeal carcinoma typically involves **Level V** (Posterior triangle) and **Level II** (Upper jugular) nodes. * **Most common site** for unknown primary presenting as a neck node: Palatine tonsil, Base of tongue, or Nasopharynx.

Q: Which stain is used for detecting early cancer in the oral and pharyngeal cavity?

Toluidine blue. **Explanation:** **Toluidine Blue (Option B)** is a basic thiazine metachromatic dye that has a high affinity for acidic tissue components, specifically **nucleic acids**. In dysplastic and malignant cells, there is an increase in DNA content (hyperchromatism) and rapid cell division. When applied topically to the oral mucosa, the dye selectively binds to these areas of high DNA density, staining them dark blue. This makes it an excellent screening tool for identifying suspicious "occult" lesions or demarcating the margins of early squamous cell carcinoma that may not be clearly visible to the naked eye. **Why the other options are incorrect:** * **Silver nitrate (Option A):** Primarily used as a cauterizing agent for aphthous ulcers or to control epistaxis (Little’s area). It is not a diagnostic stain for malignancy. * **Congo red (Option C):** This is the gold standard stain for **Amyloidosis**, showing characteristic "apple-green birefringence" under polarized light. * **Zinc chloride (Option D):** Historically used as a chemical fixative or caustic agent; it has no role in the vital staining of cancerous tissues. **High-Yield Clinical Pearls for NEET-PG:** * **Vital Staining:** Toluidine blue is a "vital stain," meaning it is applied to living tissue. * **False Positives:** Inflammatory conditions (like oral candidiasis or trauma) can also take up the stain due to increased cellular turnover, leading to false positives. * **Schiller’s Test:** Do not confuse this with the Lugol’s iodine test used for the cervix; however, Lugol’s iodine can also be used in the oral cavity to identify "iodine-negative" (malignant) areas. * **Biopsy Gold Standard:** While Toluidine blue helps in screening, a **punch biopsy** remains the definitive gold standard for diagnosing oral cancer.

Q: What is true about the AJCC staging of oral cavity carcinoma?

Involvement of the medial pterygoid muscle is stage T3.. The AJCC 8th Edition updated the staging for oral cavity carcinoma to better reflect prognostic outcomes, specifically regarding the depth of invasion (DOI) and anatomical structures involved. ### **Explanation of the Correct Option** **D. Involvement of the medial pterygoid muscle is stage T3.** In the AJCC 8th edition, the involvement of the **medial pterygoid muscle** or the **cortical bone of the mandible/maxilla** is no longer considered an automatic T4a (moderately advanced) disease. Instead, if the tumor is >4 cm or has a DOI >10 mm, or involves these specific structures without further extension, it is classified as **T3**. This change was made because involvement of the medial pterygoid alone does not carry the same poor prognosis as involvement of the deeper masticator space. ### **Why Other Options are Incorrect** * **A & B: Involvement of the pterygoid plate.** Involvement of the **pterygoid plates** (medial or lateral) signifies advanced disease that has reached the skull base region. This is classified as **T4b** (very advanced local disease). * **C: Involvement of the lateral pterygoid muscle.** While the medial pterygoid is T3, involvement of the **lateral pterygoid muscle**, the pterygoid plates, or the nasopharynx is classified as **T4b**. ### **High-Yield Clinical Pearls for NEET-PG** * **DOI vs. Thickness:** Staging now relies on **Depth of Invasion (DOI)**, not tumor thickness. DOI is measured from the level of the adjacent normal mucosa. * **T1:** $\leq$ 2 cm AND DOI $\leq$ 5 mm. * **T2:** $\leq$ 2 cm with DOI 5–10 mm OR 2–4 cm with DOI $\leq$ 10 mm. * **T3:** > 4 cm OR DOI > 10 mm OR involvement of medial pterygoid/cortical bone. * **T4a:** Invades through cortical bone into deep/extrinsic muscles of the tongue, maxillary sinus, or skin of the face. * **T4b:** Invades masticator space (lateral pterygoid), pterygoid plates, or skull base.

Question 1

Factors that have been associated with an increased incidence of head and neck carcinomas include all of the following except?

Accepted Answer

Hepatitis B virus

Answer

Syphilis

Answer

Exposure to nickel

Answer

Alcohol consumption

Question 2

What are the characteristic features of laryngeal carcinoma?

Accepted Answer

All of the above.

Answer

The glottis is the most common site.

Answer

It commonly metastasizes to cervical lymph nodes.

Answer

Lesions are often seen at the edge of the vocal cord.

Question 3

A 70-year-old male presents with a one-month history of ulceration on the lower lip with lymph node involvement. He has a 30-year history of chewing tobacco 6-7 times daily. The patient also reports unintentional weight loss for two months and a change in voice for one month. Which of the following clinical findings strongly suggests a diagnosis of malignancy?

Accepted Answer

Ulceration and fixation of the lymph node

Answer

An ulcerative lesion

Answer

An ulcerative and painful lesion

Answer

Bilateral involvement of the lymph node

Question 4

The prognosis for squamous cell carcinoma of the floor of the mouth is adversely affected by which of the following?

Accepted Answer

Poor differentiation of tumor

Answer

Nonverrucous carcinoma

Answer

Presence on the left side

Answer

No tongue involvement

Question 5

Which is the best prognosticator of survival from nasopharyngeal carcinoma?

Accepted Answer

WHO type III histology

Answer

High angiogenesis in the tumor

Answer

Lung metastases

Answer

WHO type I histology

Question 6

Involvement of neck lymph nodes is seen in all the following conditions except?

Accepted Answer

Vocal cord carcinoma

Answer

Hodgkin's lymphoma

Answer

Tumors of the hypopharynx

Answer

Nasopharyngeal carcinoma

Question 7

What is the appropriate treatment for squamous cell carcinoma of the maxilla with T3N0M0 staging?

Accepted Answer

Radiotherapy and maxillectomy

Answer

Radiotherapy

Answer

Maxillectomy

Answer

Maxillectomy and chemotherapy

Question 8

Which stain is used for detecting early cancer in the oral and pharyngeal cavity?

Accepted Answer

Toluidine blue

Answer

Silver nitrate

Answer

Congo red

Answer

Zinc chloride

Question 9

What is true about the AJCC staging of oral cavity carcinoma?

Accepted Answer

Involvement of the medial pterygoid muscle is stage T3.

Answer

Involvement of the pterygoid plate is stage T3.

Answer

Involvement of the pterygoid plate is stage T4.

Answer

Involvement of the lateral pterygoid muscle is stage T4.

Question 10

What is the treatment of choice for Carcinoma of the maxillary sinus with T3N0M0?

Accepted Answer

Surgery and Radiotherapy

Answer

Surgery

Answer

Radiotherapy

Answer

Surgery and chemotherapy

ENT Oncology — MCQs

ENT Oncology — MCQs

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