PANCE Blueprint EENT (7%)

EENT Benign and Malignant Neoplasms

Patient will present as → a 26-year-old with a lesion on her tongue. For the last 4 months, she observed an alteration on the right side of the tongue, displaying alarming growth over a three week period. The lesion is painful when the patient moves her tongue or while eating. She further mentions a recurrent, poorly healing aphthae on the right side of the tongue for a period of months before the current symptoms presented. On examination, the patient shows a symmetric face and normal skin color, motor and sensory cranial nerve functions are within normal range. No lymph nodes are palpable in her neck on both sides. On intra oral examination you note a 15 x 20m exophytic lesion with a central ulcer appearing to infiltrate the tongue musculature that appears to be relatively well demarcated.

  • Thyroid neoplastic disease (blueprint endocrinology): Papillary is the most common type
  • Oral Cancer: Most often squamous cell carcinoma (blueprint dermatology) - It has been estimated that the use of tobacco and alcohol account for up to 80 percent of cases of squamous cell carcinoma of the head and neck
  • Branchial Cleft Cyst: Cyst appearing after URI anterior to sternocleidomastoid, most common lateral neck mass
  • Thyroglossal duct cyst: Hyoid or sub-hyoid soft mass which rise with tongue protrusion, most common midline neck mass
  • Lymphadenopathy: Unilateral, painless, persistent cervical think lymphoma (blueprint hematology)
  • Leukoplakia: White oral lesion that is painless and cannot be rubbed or scraped off. Lesions are often linked with tobacco, alcohol, or denture use. About 5% are dysplastic or squamous cell carcinomas. If there is an associated erythematous appearance (erythroplakia), there is a higher risk of dysplasia or cancer (90%).

Thyroid nodules: Lesions larger than 1 cm should be biopsied

Oral cancer: Persistent papules, plaques, erosions, or ulcers in the mouth should be biopsied to rule out squamous cell carcinoma, particularly in patients with appropriate risk factors.

Lymphoma: Other causes of lymphadenopathy should be excluded, such as syphilis, HIV, and mononucleosis. Persistent, unexplained, enlarged nodes should be biopsied. Reed–Sternberg cells confirm the diagnosis Hodgkins Lymphoma.

Leukoplakia: Leukoplakia itself is a benign reactive process. However, between 1 and 20 percent of lesions will progress to carcinoma within 10 years.

Treatment is based on the etiology. Refer to the following blueprint lessons:

Thyroglossal-Duct-Cyst

Thyroglossal Cyst is an abnormal growth on the neck it is an oral cyst developing from epithelium which is nested in bony or soft-tissue joints during embryonal development.

Question 1
In addition to tobacco products, which of the following is also considered a major risk factor in the development of oral cancer?
A
Sun exposure
Hint:
Sun exposure is a risk factor for cancer of the lip, but is not considered a major risk factor for oral cancer.
B
Alcohol abuse
C
Occupational exposure
Hint:
While occupational exposures and presence of premalignant lesions, such as leukoplakia, are risk factors for development of oral cancer, they are not considered major risk factors.
D
History of oral candidiasis
Hint:
History of oral candidiasis has no correlation to development of oral cancer.
Question 2
Bitemporal hemianopia is noted on physical examination in a patient with visual changes over the past 2 years. The central field of vision is spared. The lesion is located in the
A
optic nerve
Hint:
A lesion in the optic nerve would result in loss of vision in the affected eye only and include loss of central vision.
B
optic chiasm
C
temporal optic radiation
Hint:
A lesion in the temporal optic radiation would produce superior contralateral quadrantanopia.
D
optic tract
Question 2 Explanation: 
A lesion in the optic chiasm would result in the loss of vision in the bilateral temporal fields and spare the central field of vision.
Question 3
Closure of the eyelids is mediated by which cranial nerve?
A
cranial nerve III
Hint:
Cranial nerve III is involved in extraocular movement and controls opening of the eyelids but has no control over closing the eyelids.
B
cranial nerve V
Hint:
Cranial nerve V controls the motor function of the temporal and masseter muscles and facial sensation. It has no control over eyelid closure.
C
cranial nerve VII
D
cranial nerve IX
Question 3 Explanation: 
Cranial nerve VII controls the motor function of the facial muscles not controlled by cranial nerve V (forehead, eyebrows, mouth, and lips) including closing of the eyelids
Question 4
Which of the following would indicate an optic nerve lesion?
A
Excessive conjunctival edema
Hint:
Excessive edema of the conjunctiva is a feature of chemosis.
B
Ptosis
Hint:
Ptosis is not indicative of an optic nerve lesion.
C
Inability to gaze laterally
Hint:
Inability to gaze laterally would be due to paralysis of the lateral rectus muscle controlled by cranial nerve VI.
D
Afferent pupillary defect
Question 4 Explanation: 
Pupil size, controlled centrally by the Edinger-Westphal nucleus in the midbrain, is primarily based on the afferent light stimulus transmitted via the optic nerve.
Question 5
A 60 year-old patient with a history of tobacco and alcohol abuse presents for a routine physical. Which of the following physical examination findings is suspicious for oral carcinoma?
A
Painful creamy-white patches overlying erythema
Hint:
Oral candidiasis is characterized by painful creamy white patches overlying erythema.
B
Red smooth surface tongue
Hint:
Red smooth tongue is characteristic of glossitis which is most commonly associated with nutritional deficiencies.
C
Small vesicles on an erythematous base
Hint:
Small vesicles on erythematous bases are characteristic of herpetic stomatitis.
D
White lesion that cannot be removed by rubbing
Question 5 Explanation: 
Leukoplakia, premalignant lesions, are white lesions that can not be removed by rubbing.
Question 6
Lesions of the optic chiasm will produce which of the following conditions?
A
Amaurosis fugax
Hint:
See B for explanation.
B
Bitemporal hemianopia
C
Unilateral blindness
Hint:
See B for explanation.
D
Homonymous hemianopia
Hint:
See B for explanation.
Question 6 Explanation: 
A lesion of the optic chiasm will produce bitemporal hemianopia.
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