VIQ - Head and Neck

Question 1

@# 33. A 65 year old woman is investigated for enophthalmos and headache. She is cachetic, anaemic and you suspect a metastatic process. CT head demonstrates an infiltrative retrobulbar mass. What is the most likely site of primary disease?

a. Breast

b. Lung

c. Renal

d. Melanoma

e. Ovarian

Answer 1

33. a. Breast

Most retrobulbar metastases are extraconal (outside the muscle cone).

Neuroblastoma and Ewing’s sarcoma are the most common in children and produce smooth extraconal masses related to the posterior lateral wall of the orbit.

In adults, an infiltrative retrobulbar mass and enophthalmos is characteristic of scirrhous carcinoma of the breast (invasive ductal carcinoma).

Enophthalmia is also considered to be one of the earliest signs of metastatic breast cancer.

Question 2

@# QUESTION 12
A 46-year-old woman presents with a painful left eye. She has enophthalmos on clinical examination. CT reveals a mass arising from the greater wing of the left sphenoid with some underlying bone destruction. The mass is poorly marginated and infiltrating die intraconal compartment. What is the most likely diagnosis?

A Caroticocavernous fistula

B Lymphoma

C Metastatic breast carcinoma

D Orbital dermoid

E Orbital varix

Answer 2

C Metastatic breast carcinoma

This is a characteristic appearance of metastatic scirrhous breast carcinoma

Question 3

@# QUESTION 23 A GP requests your advice regarding an 18-month-old girl whose mother has noticed that her left pupil appears white. The GP has performed ophthalmoscopy and is suspicious that there is a retinal mass. Which one of the following is the investigation of choice?

A CT orbits

B MRI orbits

C Orbital radiographs

D Repeat ophthalmoscopy by ophthalmologist

E Ultrasound

Answer 3

A CT orbits

CT is the best initial investigation as it is sensitive to calcification in retinoblastoma. If there is calcification within an ocular mass in a child under 3 years of age, it is considered to be retinoblastoma until proven otherwise.

Question 4

@#e 7 A 55-year-old gentleman was investigated for sudden onset visual loss affecting the right temporal region. Ultrasound of the globe demonstrated right-sided retinal detachment with an associated well-defined flat echogenic mass was seen. An uveal melanoma was suspected and a MRI scan performed. What are the likely signal characteristics of the lesion?

a High signal on both Ti- and T2-weighted imaging

b High signal on T1-weighted imaging and intermediate on T2

C High signal on T1-weighted imaging and intermediate on T2

d High signal on T1-weighted imaging and intermediate on T2

e Low signal on both Ti- and T2-weighted imaging

Answer 4

7 Answer A: High signal on both Ti- and T2-weighted imaging

Orbital melanomas are high signal on both Ti- and T2-weighted imaging. They are the commonest intraocular primary in adults, arise from the choroids plexus and are associated with retinal detachment, vitreous haemorrhage and glaucoma.

Question 5

@# 5. Which of the following is a feature of a 15-year-old boy with juvenile angiomyofibroma?

A. Posterior bowing of the posterior antral wall

B. Invasion of the frontal sinuses

C. Widening of the superior orbital fissure

D. Delayed enhancement on CT

E. Intermediate SI on T1 with punctuate areas of Hyperdensity

Answer 5

C. Widening of the superior orbital fissure

Widening of the pterygopalatine fossa with anterior bowing of the posterior antral wall, invasion of the sphenoid sinus (in 2/3), widening of the superior and inferior orbital fissures, and immediate enhancement after contrast injection are all features. On MR, punctuate hypodensities on T1 are due to the highly vascularised stroma.

Question 6

@# 13 A middle-aged man presents with an acute onset facial nerve palsy and has MR imaging with the i. v. administration of gadolinium. Which of the following features would support the diagnosis of a Bell’s palsy?

(a) Enhancement of the tympanic portion of the facial nerve

(b) Enhancement of the intracanalicular portion of the facial nerve

(c) Enhancement of the mastoid portion of the facial nerve

(d) Continuing symptoms at 9 months

(e) Demineralisation of the petrous apex

Answer 6

(b) Enhancement of the intracanalicular portion of the facial nerve

Although non-specific, enhancement of the intracanalicular and labyrinthine portion occurs in Bell’s palsy (other inflammatory and neoplastic conditions should also be considered).

Enhancement of the tympanic and mastoid portions of the facial nerve is a normal variant.

Demineralisation does not occur.

Question 7

@# 59 A patient presents with pulsatile tinnitus. CT reveals a mass in the left temporal bone and there is focal uptake with 111 1n octreotide imaging. Which of the following is least likely?

(a) Glomus tympanicum

(b) Meningioma

(c) Carcinoid metastasis

(d) Small cell cancer metastasis

(e) Metastasis of papillary carcinoma of the thyroid

Answer 7

(e) Metastasis of papillary carcinoma of the thyroid

Octreotide is a somatostatin analogue, and uptake is seen where somatostain receptors are expressed, such as neuroendrocine tumours (e.g., glomus tympanicum), and other malignancies (e.g., small cell lung cancer, lymphoma, and breast cancer). There is also uptake in a few tumours that do not express the receptor (e.g., meningioma, astrocytoma).

Question 8

@# (Ped) 82) A 13-year-old male presents with recurrent epistaxis. CT shows a highly vascular mass in the nasopharynx, with widening of the pterygopalatine fossa and invasion of the sphenoid sinus. Which arterial branch is the feeding vessel likely to be arising from?

a. ascending pharyngeal

b. facial artery

c. superficial temporal artery

d. internal maxillary artery

e. internal carotid artery

Answer 8

d. internal maxillary artery

Juvenile angiofibromas are the commonest benign tumour of the nasopharynx and can grow to enormous sizes. They tend to present in teenagers with recurrent and severe epistaxis, as well as nasal obstruction. They are highly vascular and biopsy is contraindicated. In most cases, they are supplied primarily by the internal maxillary artery

Question 9

@# 7 A 30 year old man with learning difficulties presents· to A&E after suffering facial injuries. An orthopantomogram is performed and demonstrates a multi-locular radiolucent lesion in the angle of the mandible. He suffered from multiple carcinomatous lesions of the skin in childhood. What is the most likely diagnosis?

(a) Odontogenic keratocyst

(b) Dentigerous cyst

(c) Inflammatory odontogenic cyst

(d) Ameloblastoma

(e) Multiple myeloma

Answer 9

(a) Odontogenic keratocyst

This patient suffers from Gorlin-Goltz/ basal cell naevus syndrome, associated with multiple cutaneous basal cell carcinomas during childhood, odontogenic keratocysts, ectopic calcifications, and multiple skeletal anomalies. Mental retardation is another recognized association. All of the above answers above can present as cystic lesions of the jaw.

Question 10

@# 48 Which of the following is not involved in a Le Fort type II fracture?

(a) Pterygoid plates

(b) Orbital floor

(c) Anterior wall of the maxillary sinus

(d) Postero-lateral wall of the maxillary sinus

(e) Medial wall of the maxillary sinus

Answer 10

(e) Medial wall of the maxillary sinus

The medial wall of the maxillary sinus is spared in a type II fracture.

The pterygoid plates are involved in all Le Fort fractures.

Question 11

QUESTION 16
@# A 21-year-old man has facial and mandibular radiographs following minor trauma. These show no evidence of fracture, however there are multiple dense bony lesions arising from the paranasal sinuses and the angle and ramus of the mandible. These lesions are entirely asymptomatic. Which one of the following conditions may be associated with these findings?

A Gardner’s syndrome

B Gorlin-Goltz syndrome

C Juvenile polyposis

D Klippel-Feil syndrome

E Turner’s syndrome

Answer 11

A Gardner’s syndrome

Multiple maxillofacial osteomas are a feature of familial adenomatous polyposis (or Gardner’s syndrome). They precede the colonic polyposis.

Question 12

@# QUESTION 40
A 14-year-old girl with a kyphoscoliosis has multiple skin lesions which have been characterised as basal cell tumours. In addition she has had investigations which have revealed calcification of the falx and several bifid ribs. Which of the following findings would be most likely on a dental panoramic radiograph?

A A large well-defined lucency inferior to the inferior alveolar canal

B Multiple ill-defined lucent lesions

C Multiple sclerotic lesions, particularly around the angle of the mandible

D Multiple small periapical lucencies

E Multiple well-defined multiloculated lucencies

Answer 12

E Multiple well-defined multiloculated lucencies

This is Gorlin-Goltz syndrome, in which there are multiple odontogenic keratocysts

Question 13

@# QUESTION 45
A 24-year-old woman presents to her GP with jaw stiffness and headaches. Her partner complains that she grinds her teeth during the night. She attends for an MRI scan to visualise the temporomandibular joints. Sequences are performed with the mouth open and closed. Which of the following radiological findings are most likely?

A Anterolateral displacement of the biconcave articular disc on mouth closing

B Anteromedial displacement of the biconcave articular disc on mouth opening

C Anteromedial displacement of the biconvex articular disc on mouth opening

D Posterior displacement of the biconcave articular disc on mouth opening

E Posterior displacement of the biconvex articular disc on mouth opening

Answer 13

B Anteromedial displacement of the biconcave articular disc on mouth opening

Question 14

@# 1 An orthopantomogram (OPG) was requested following trauma. No fractures are visible on the film, but there is loss of the lamina dura and a well-defined expansile lyric lesion affecting the ramus of the mandible. This lesion has a narrow zone of transition and no associated soft-tissue mass. The bones are diffusely osteopaenic. What is the most appropriate investigation?

a CT scan

b Biopsy of the mass

c ESR

d PTH level

e Calcium level

Answer 14

1 Answer D: PTH level

This patient has hyperparathyroidism and the lyric mass is a brown tumour. Generalised loss of the lamina dura is seen in osteoporosis, osteomalacia, Paget’s disease, scleroderma and hyperparathyroidism. The description is typical for a brown tumour and these are most commonly seen in primary hyperparathyroidism. The jaw is the most common site for these tumours.

Question 15

@# 22 A young man presents to the ENT Department with a painless palpable soft-tissue swelling in the right perialveolar region. Contrast-enhanced CT revealed an inhomogeneous contrast-enhancing mass in the mandible. On bony windows the mass was a multilocular cyst with a thin sclerotic margin and a narrow zone of transition. The patient had gingival disease. Which is the most likely diagnosis?

a Giant cell granuloma

b Pleomorphic adenoma

c Oropharyngeal carcinoma

d Lymphoma

e Nasopharyngeal angiofibroma

Answer 15

22 Answer A: Giant cell granuloma

GCG is thought to be a reactive inflammatory process resulting in overgrowth of tissue in response to trauma or infection. They are more common in the mandibular region than the maxillary region and are less than 2 cm in size. Patients with GCG typically present early in adult life with a male to female ratio of 1:1. GCG is associated with Paget’s disease and fibrous dysplasia. Gingivitis is a risk factor.

Question 16

@# 8 A neck lump is found on clinical examination. Axial MR images of the neck demonstrate a mass displacing the parapharyngeal space posteromedially and the styloid musculature posteriorly. In which fascial space is the mass most likely to be located?

(a) Masticator space

(b) Carotid space

(c) Pharyngeal mucosal space

(d) Parotid space

(e) Retropharyngeal space

Answer 16

(a) Masticator space

The displacement of the parapharyngeal space and styloid musculature can help localise neck lesions:

Question 17

@# 13. A 20 year old female is under investigation for periodic halitosis. A CT scan reveals a well-defined, hypodense mass located between the longus colli muscles. There is no enhancement post-contrast injection. MRI demonstrates a midline cystic structure in the posterior roof of the nasopharynx. It shows high signal intensity on both T1 and T2 sequences. The most likely diagnosis is:

a. Benign polyp

b. Rathke’s pouch cyst

c. Ranulas

d. Tornwaldt’s cyst

e. Thyroglossal duct cyst

Answer 17

13.d. Tornwaldt’s cyst

Tornwaldt’s cyst is a benign mass typically located in the midline, between the longis colli muscles, in the posterior nasopharynx. They arise as a result of a focal adhesion between the ectoderm and regressing notochord. This causes the creation of a pouch but when the communication with the pouch is lost, a cyst develops. Tornwaldt’s cysts are usually asymptomatic and are picked up as incidental findings. Periodically, the pressure within the cyst increases causing the release of its contents into the nasopharynx. This leads to presentations including halitosis, foul taste in the mouth and persistent nasopharyngeal drainage. Peak age at presentation is 15–30 years. Imaging features can vary depending on the protein content within the cyst but typical features are of a well-delineated, thin-walled, midline cystic lesion measuring 2–10 mm in diameter. They are hypodense on CT, rarely calcify and do not enhance. They can be high or low on T1 (depending on protein content) but are high on T2 imaging. Rathke’s pouch cysts are located anterior and cephalad to Tornwaldt’s cysts.

Question 18

@# QUESTION 74
A 48-year-old woman presents to her GP with a midline neck mass which has been growing slowly over many months. On examination, she has a welldefined lump in the suprasternal notch and she is referred for an ultrasound. This shows a predominantly cystic lesion with some internal echoes. There is also a single echogenic focus within the lesion which has dense posterior acoustic shadowing. What is the most likely diagnosis?

A Dermoid cyst

B Epidermoid cyst

C Haemorrhagic thyroid nodule

D Ranula

E Thymic cyst

Answer 18

A Dermoid cyst

Dermoid cysts are the commonest teratoma in the head and neck. This scenario describes a cyst with cellular contents as well as an osseodental structure. CT and MRI may show globules of fat with fat and/or fluid levels.

Question 19

@# 42. You are reporting a CT scan of neck in a patient with a head and neck cancer. You see an enlarged necrotic jugulo-digastric lymph node on the right side and wish to describe the appropriate level of this lymph node in your report. What is the correct level?

A. I.

B. II.

C. III.

D. IV.

E. V.

F. VI.

G. VII.

Answer 19

42. B. II.

Lymph nodes in the neck have been divided into seven levels, generally for the purpose of squamous cell carcinoma staging. This is, however, not all inclusive, as the parotid nodes and retropharyngeal space nodes are not included in this system.
Level I: Below mylohyoid to hyoid bone anteriorly
Level Ia: Submental Level Ib: Submandibular
Level II: Jugulodigastric (base of skull to hyoid)
Level III: Deep cervical (hyoid to cricoid)
Level IV: Virchow (cricoid to clavicle)
Level V: Posterior triangle groups
Level Va: Accessory spinal (posterior triangle), superior half
Level Vb: Accessory spinal (posterior triangle), inferior half
Level VI: Prelaryngeal/pretracheal/Delphian node
Level VII: Superior mediastinal (between common carotid arteries (CCAs), below top of manubrium) Lymph node levels of the neck.

Question 20

@# 45. A 50-year-old male undergoes an MR carotid angiogram on which an incidental soft-tissue mass is noted in right parapharyngeal soft tissue. The mass displaces the right parapharyngeal space anteromedially. What is the location of the soft-tissue mass?

A. Masticator space.

B. Carotid space.

C. Retropharyngeal space.

D. Mucosal space.

E. Parotid space

Answer 20

45. E. Parotid space.

Loss of symmetry and displacement of the parapharyngeal space are useful for lesion identification and localization in the parapharyngeal soft tissues.

A thorough knowledge of the anatomical relationship between the spaces is essential.

The parapharyngeal space is shaped like an inverted pyramid with the apex pointing inferiorly toward the greater cornu of the hyoid bone and the skull base demarcates the base superiorly.

A lesion arising from the parotid space displaces the fat in the parapharyngeal space anteromedially.

A lesion in the masticator space displaces the parapharyngeal fat posteromedially.

Carotid space lesions displace it anteriorly,

mucosal space lesions displace it posterolaterally,

and retropharyngeal space lesions displace it anterolaterally.

Posterior displacement of the carotid space or parapharyngeal fat completely surrounding a lesion localizes it to the parapharyngeal space.

Question 21

@# 49. On a thyroid radioisotope study, which is a cause of a hot thyroid nodule?

A. Involutional nodule

B. Focal thyroiditis

C. Adenomatous hyperplasia

D. Granuloma

E. Abscess

Answer 21

C. Adenomatous hyperplasia

Other causes include autonomous adenoma and, very rarely, thyroid cancer. Any hot nodule on Tc-99m should be imaged with I-123 to differentiate between autonomous and cancerous lesions.

Question 22

@# 10) A 46-year-old patient presents with an enlarged level IV lymph node in the neck. Histology from FNA demonstrates metastatic squamous cell carcinoma. Which of the following is the most likely site of the primary malignancy?

a. oral cavity

b. nasopharynx

c. tongue

d. salivary gland

e. larynx

Answer 22

e. larynx

The lymph node chains in the neck are complex and consist of a superficial circular nodal group and a deep cervical chain.

Supraglottic laryngeal squamous cell carcinoma tends to spread to the high internal jugular vein chain of nodes, which are in level II, with tumours of the epiglottis, aryepiglottic folds and pyriform sinuses most likely to present with adenopathy.

This can be ipsilateral (most common), contralateral or bilateral.

Subglottic tumours tend to spread to bilateral middle- or lower-level nodes of the internal jugular vein chain in level III or IV.

The level IV lymph nodes also drain the hypopharynx, thyroid and upper oesophagus.

The oral cavity, including the tongue and nasopharynx, drains to the level II nodes.

The salivary glands drain to level I or II nodes.

Tumours confined to the vocal folds do not normally metastasize to lymph nodes.

Question 23

@# 26) A 43-year-old man presents with cough and numerous masses in the neck bilaterally. CT confirms multiple lymph nodes that enhance peripherally and contain areas of calcification. A cavitating lesion is noted in the right lung apex. What is the most likely diagnosis?

a. tuberculosis

b. metastatic laryngeal carcinoma

c. metastatic nasopharyngeal carcinoma

d. metastatic papillary thyroid carcinoma

e. metastatic squamous cell carcinoma of the lung

Answer 23

a. tuberculosis

Tuberculous lymphadenitis is the most common form of head and neck tuberculosis, representing 15% of all extrapulmonary tuberculous infections.

It is frequently bilateral and, the more inferior the involved nodes, the higher the prevalence of associated pulmonary disease.

Peripherally enhancing lymph nodes are seen with tuberculosis, metastatic disease (usually squamous cell tumours), lymphoma or infection.

The presence of calcification suggests tuberculosis, but it may also be seen with papillary or medullary thyroid carcinoma.

The other diagnoses listed may cause cervical lymphadenopathy, but the lung lesion would be unusual in all except a cavitating squamous cell carcinoma of the lung.

Question 24

@# 30. Regarding radionuclide imaging of thyroid cancers, which radiological finding best fits the diagnosis?

a. Usually concentrates radioiodine – follicular carcinoma

b. Usually concentrates pertechnetate – papillary carcinoma

c. Usually concentrates pertechnetate and radioiodine – papillary carcinoma

d. No radioiodine or pertechnetate uptake but frequently concentrates thallium-201 – medullary carcinoma

e. No radioiodine or pertechnetate uptake but frequently concentrates thallium-201 – anaplastic carcinoma

Answer 24

30. d. No radioiodine or pertechnetate uptake but frequently concentrates thallium-201 – medullary carcinoma

Types of thyroid carcinoma in order of worsening prognosis are papillary, follicular, medullary and anaplastic.

Papillary tumours usually concentrate radioiodine,

follicular tumours concentrate pertechnetate but fail to accumulate radioiodine,

and anaplastic tumours show no radioiodine uptake.