Neck Practice Questions

Q: When a large bolus of food is swallowed, the hyoid bone moves anteriorly to open the pharynx. The muscle responsible for this action is innervated by which of the following nerves?

C1 (ansa cervicalis). **Explanation:** The muscle responsible for the anterior movement of the hyoid bone (and consequently the larynx) to open the pharynx during swallowing is the **Geniohyoid**. 1. **Why A is correct:** The geniohyoid muscle originates from the inferior mental spine of the mandible and inserts into the hyoid bone. When it contracts, it pulls the hyoid bone anterosuperiorly, widening the pharynx to accommodate a food bolus. It is innervated by the **C1 nerve fibers** traveling via the **Hypoglossal nerve (CN XII)**. While it is technically "C1 via XII," in the context of NEET-PG, it is categorized under the C1/Ansa cervicalis complex. 2. **Why the others are wrong:** * **CN IX (Glossopharyngeal):** Innervates the Stylopharyngeus. While this muscle elevates the pharynx, it does not primarily drive the anterior displacement of the hyoid. * **Pharyngeal Plexus:** Formed by CN IX, X, and sympathetic fibers. It innervates most pharyngeal constrictors and palatal muscles (except Tensor Veli Palatini and Stylopharyngeus), which are involved in peristalsis, not anterior hyoid displacement. * **CN V3 (Mandibular nerve):** Innervates the Mylohyoid and the anterior belly of the digastric. While these elevate the hyoid, the specific "anterior" pull for pharyngeal opening is the hallmark of the Geniohyoid. **High-Yield NEET-PG Pearls:** * **C1 via CN XII:** Supplies two muscles—the **Geniohyoid** and the **Thyrohyoid**. * **Ansa Cervicalis (C1-C3):** Supplies the "SOS" muscles—**S**ternohyoid, **O**mohyoid, and **S**ternothyroid. * **Deglutition Tip:** The elevation and anterior displacement of the larynx under the tongue base is essential to protect the airway and open the esophagus.

Q: A 45-year-old woman presents with neck pain. A CT scan reveals a tumor in the left side of her oral cavity. Following a radical neck surgical procedure for tumor removal, the patient's left shoulder droops noticeably two months postoperatively. Physical examination reveals distinct weakness in turning her head to the right and impairment of abduction of her left upper limb to the level of the shoulder. Which of the following structures was most likely injured during the radical neck surgery?

Spinal accessory nerve. ### Explanation **1. Why the Spinal Accessory Nerve (CN XI) is correct:** The clinical presentation of **shoulder drooping** and **weakness in head rotation** is a classic sign of Spinal Accessory Nerve injury. * **Trapezius muscle:** CN XI provides motor innervation to the trapezius. Paralysis leads to drooping of the shoulder and an inability to abduct the arm above 90 degrees (as the trapezius is essential for upward rotation of the scapula). * **Sternocleidomastoid (SCM) muscle:** CN XI also innervates the SCM. Since the left SCM rotates the head to the *right*, an injury to the left nerve results in weakness when turning the head to the opposite side. * **Surgical Context:** The Spinal Accessory Nerve is highly vulnerable during radical neck dissections as it crosses the posterior triangle of the neck. **2. Why the other options are incorrect:** * **A. Suprascapular nerve:** Innervates the supraspinatus (initiates abduction) and infraspinatus. While injury affects abduction, it would not cause SCM weakness or shoulder drooping. * **B. Long thoracic nerve:** Innervates the serratus anterior. Injury causes "winging of the scapula," not a drooping shoulder or SCM deficit. * **D. Junction of C5-C6 (Erb’s Point):** Injury here (Erb’s Palsy) leads to the "waiter’s tip" deformity. While it affects abduction, it involves multiple muscles (deltoid, biceps, brachialis) and would not explain the SCM weakness. **3. NEET-PG Clinical Pearls:** * **Surface Anatomy:** The Spinal Accessory Nerve emerges at the junction of the upper 1/3rd and lower 2/3rds of the posterior border of the SCM. * **The "Shrug" Test:** Clinical testing for CN XI involves shrugging the shoulders against resistance (Trapezius) and turning the chin against resistance (SCM). * **Iatrogenic Injury:** The most common cause of CN XI injury is iatrogenic, specifically during lymph node biopsies in the posterior triangle or radical neck surgeries.

Q: Into which lymph node do the lymphatics of the tonsils primarily drain?

Jugulodigastric lymph node. The palatine tonsils are part of the Waldeyer’s ring and have a specific lymphatic drainage pattern that is frequently tested in NEET-PG. ### **Explanation of the Correct Answer** The **Jugulodigastric lymph node** (also known as the **Principal lymph node of the tonsil**) is the primary site for tonsillar drainage. It is located in the deep cervical chain, specifically where the posterior belly of the digastric muscle crosses the internal jugular vein. Because it is the first station to receive lymph from the palatine tonsils, it is the most common node to become enlarged and tender during acute tonsillitis. ### **Analysis of Incorrect Options** * **B. Jugulo-omohyoid lymph node:** This node is located where the omohyoid muscle crosses the internal jugular vein. It primarily receives drainage from the **tongue** (specifically the submental and submandibular nodes) and is not the primary station for the tonsils. * **C. Submandibular lymph node:** These nodes receive lymph from the front of the scalp, nose, cheeks, upper lip, and the lateral parts of the lower lip and tongue. * **D. Submental lymph node:** These nodes drain the tip of the tongue, the floor of the mouth, and the central part of the lower lip. ### **High-Yield Clinical Pearls for NEET-PG** * **Location:** The Jugulodigastric node belongs to the **Level II** cervical lymph nodes. * **Clinical Sign:** In clinical practice, a palpable, tender jugulodigastric node is a hallmark sign of **acute follicular tonsillitis**. * **Waldeyer’s Ring:** Remember that while the palatine tonsils drain to the jugulodigastric nodes, the pharyngeal tonsils (adenoids) drain primarily to the **retropharyngeal lymph nodes**.

Q: An angiogram of a man shows an occlusion of the Costocervical Trunk. This obstruction could produce a marked decrease in the blood flow in which of the following arteries?

Deep cervical artery. The **Costocervical Trunk** is a short branch arising from the posterior aspect of the **second part of the subclavian artery** (on the right) or the first part (on the left). It travels posteriorly over the cervical pleura to the neck of the first rib, where it divides into two terminal branches: 1. **Deep Cervical Artery:** It passes backward between the transverse process of C7 and the first rib, ascending the back of the neck to anastomose with the descending branch of the occipital artery. 2. **Superior Intercostal Artery:** It descends in front of the necks of the first two ribs to provide the first and second posterior intercostal arteries. Therefore, an occlusion of the costocervical trunk directly compromises blood flow to the **Deep cervical artery**. **Analysis of Incorrect Options:** * **A. Superior thoracic artery:** This is the first branch of the **Axillary artery**, supplying the first and second intercostal spaces. * **B. Transverse cervical artery:** This is a branch of the **Thyrocervical trunk** (from the 1st part of the subclavian artery). * **C. Ascending cervical artery:** This is a small branch of the **Inferior thyroid artery** (which itself arises from the Thyrocervical trunk). **High-Yield NEET-PG Pearls:** * **Subclavian Artery Parts:** Divided by the **Scalenus Anterior** muscle. 1st part (medial), 2nd part (posterior/behind), 3rd part (lateral). * **Branches of 1st Part:** Vertebral artery, Internal thoracic artery, Thyrocervical trunk (VIT). * **Branches of 2nd Part:** Costocervical trunk. * **Branches of 3rd Part:** Dorsal scapular artery (variable). * **Collateral Circulation:** The anastomosis between the Deep Cervical artery and the Occipital artery is a vital link between the Subclavian and External Carotid systems.

Q: During surgery for squamous cell carcinoma of the neck in a 56-year-old man, the surgeon encounters profuse bleeding from a deep cervical artery. Which of the following arteries must be ligated immediately to control the bleeding?

Costocervical trunk. **Explanation:** The **deep cervical artery** is a direct branch of the **costocervical trunk**. To control profuse bleeding from this vessel, the parent trunk must be ligated. **1. Why Option A is Correct:** The costocervical trunk arises from the second part of the subclavian artery (on the right) or the first part (on the left). It divides into two main branches: * **Deep cervical artery:** Passes posteriorly above the T1 nerve to supply the deep muscles of the back of the neck. * **Superior intercostal artery:** Supplies the first two intercostal spaces. Since the deep cervical artery originates from this trunk, ligating the costocervical trunk is the most proximal and effective way to control the hemorrhage. **2. Why Other Options are Incorrect:** * **B. Transverse cervical artery:** This is a branch of the thyrocervical trunk. It supplies the trapezius and rhomboid muscles but does not give rise to the deep cervical artery. * **C. Thyrocervical trunk:** While it is a major branch of the first part of the subclavian artery, its primary branches are the inferior thyroid, suprascapular, and transverse cervical arteries. It does not supply the deep cervical artery. * **D. Inferior thyroid artery:** This is a branch of the thyrocervical trunk. It supplies the thyroid gland and gives off the ascending cervical artery, which is more superficial than the deep cervical artery. **High-Yield NEET-PG Pearls:** * **Subclavian Artery Parts:** Divided by the **scalenus anterior** muscle. * 1st Part: Vertebral, Internal thoracic, Thyrocervical trunk. * 2nd Part: Costocervical trunk (on the right). * 3rd Part: Dorsal scapular artery (variable). * **Deep Cervical Artery Anastomosis:** It anastomoses with the descending branch of the **occipital artery** (from the external carotid), providing a critical collateral channel between the subclavian and external carotid systems.

Q: The larynx extends from which vertebral level?

C3-C6. **Explanation:** The larynx, also known as the "voice box," is a cartilaginous structure that serves as a vital air passage and the organ of phonation. In an adult, it extends from the **upper border of the epiglottis to the lower border of the cricoid cartilage**. **1. Why C3-C6 is correct:** The vertical extent of the larynx corresponds to the level of the **C3 to C6 vertebrae**. * **C3:** Level of the hyoid bone and the upper limit of the epiglottis. * **C4-C5:** Level of the thyroid cartilage (the "Adam’s apple"). * **C6:** Level of the cricoid cartilage, marking the termination of the larynx and the beginning of the trachea. **2. Analysis of Incorrect Options:** * **C2-C7 (A):** This range is too broad. C2 is the level of the axis (oropharynx), and C7 is well into the trachea. * **C1-C4 (B):** This corresponds more closely to the position of the pharynx and the upper cervical spine; the larynx begins lower. * **C5-C6 (C):** While the larynx occupies this space, it is incomplete as it misses the superior structures (epiglottis and hyoid) located at C3-C4. **3. NEET-PG High-Yield Pearls:** * **Pediatric Anatomy:** In infants, the larynx is situated much higher (approx. **C2-C3**) to allow simultaneous breathing and nursing. It descends to the adult position by puberty. * **The C6 Level:** This is a "critical level" in the neck. It marks the end of the larynx/pharynx and the start of the trachea/esophagus. It is also where the middle thyroid artery enters and the carotid tubercle (Chassaignac's tubercle) is located. * **Inlet vs. Outlet:** The laryngeal inlet faces the oropharynx, while the outlet is continuous with the trachea at the lower border of the cricoid.

Q: At the bifurcation of the common carotid artery, where is the internal carotid artery located in relation to the external carotid artery?

Lateral to the external carotid artery.. The common carotid artery (CCA) typically bifurcates at the level of the upper border of the thyroid cartilage (C3-C4 vertebral level). At this point of origin, the **Internal Carotid Artery (ICA)** lies **posterolateral** to the **External Carotid Artery (ECA)**. 1. **Why Option A is correct:** Although the ICA eventually moves medially to enter the carotid canal at the base of the skull, at its immediate origin (the carotid bulb), it is situated lateral and slightly posterior to the ECA. This anatomical arrangement is a high-yield fact for surgical orientation during procedures like carotid endarterectomy [1]. 2. **Why Options B, C, and D are incorrect:** * **Medial/Anterior:** These describe the initial position of the **External Carotid Artery**. The ECA begins anteromedial to the ICA before coursing upwards and backwards. * **Posterior:** While the ICA has a posterior component to its position, "Lateral" is the primary descriptor used in standard anatomical texts (Gray’s Anatomy) to differentiate its starting position from the ECA. **NEET-PG High-Yield Pearls:** * **Branches:** The ICA has **no branches** in the neck. This is the most reliable way to distinguish it from the ECA during surgery. * **Carotid Sinus:** Located at the bifurcation (primarily involving the proximal ICA), it acts as a **baroreceptor** (pressure sensor) innervated by the Glossopharyngeal nerve (CN IX). * **Carotid Body:** A small, reddish-brown structure located posterior to the bifurcation; it acts as a **chemoreceptor** (sensing $O_2$, $CO_2$, and pH). * **Surface Anatomy:** The bifurcation corresponds to the level of the **disc between C3 and C4 vertebrae**.

Q: During the excision of cervical lymph nodes, inadvertent injury to which nerve causes drooping of the shoulder?

Spinal accessory nerve. **Explanation:** The correct answer is **Spinal accessory nerve (CN XI)**. **1. Why it is correct:** The spinal accessory nerve (CN XI) exits the skull through the jugular foramen and descends to supply the sternocleidomastoid muscle. It then crosses the **posterior triangle of the neck**, where it lies superficially, covered only by skin and fascia [1]. It terminates by supplying the **trapezius muscle**. The trapezius is the primary muscle responsible for elevating the scapula and maintaining the shoulder's contour. Injury to CN XI during cervical lymph node biopsy or neck dissection leads to paralysis of the trapezius, resulting in **drooping of the shoulder**, inability to shrug, and difficulty in abducting the arm above the horizontal plane (due to loss of scapular rotation) [1]. **2. Why the other options are wrong:** * **Supraclavicular nerve:** These are cutaneous sensory nerves (C3-C4). Injury would cause sensory loss over the shoulder and upper chest, but no motor deficit or drooping. * **Suprascapular nerve:** Supplies the supraspinatus and infraspinatus. Injury causes weakness in initiating abduction and external rotation of the arm, but not shoulder drooping. * **Nerve to serratus anterior (Long thoracic nerve):** Injury leads to **"winging of the scapula"** (medial border protrudes), but the shoulder does not droop. **High-Yield Clinical Pearls for NEET-PG:** * **Surface Anatomy:** The spinal accessory nerve is most vulnerable at **Erb’s point** (middle of the posterior border of the sternocleidomastoid). * **Clinical Test:** Ask the patient to shrug their shoulders against resistance to test the trapezius (CN XI). * **Iatrogenic Injury:** Cervical lymph node biopsy in the posterior triangle is the most common cause of iatrogenic spinal accessory nerve palsy [1].

Q: The oropharynx lies against which cervical vertebra?

C2. The pharynx is a muscular tube extending from the base of the skull to the lower border of the cricoid cartilage. For NEET-PG, it is essential to memorize the vertebral levels of its three subdivisions: **1. Why C2 is the correct answer:** The **oropharynx** is the middle portion of the pharynx, located posterior to the oral cavity. It extends from the soft palate above to the upper border of the epiglottis below. Anatomically, it lies anterior to the **C2 (Axis) and the upper part of the C3** vertebrae. In most standard anatomical texts and exam patterns, C2 is identified as the primary vertebral relation for the oropharynx. **2. Analysis of incorrect options:** * **C1 (Atlas):** This level corresponds to the **Nasopharynx**, which lies above the soft palate and extends from the base of the skull to C1. * **C3:** While the lower limit of the oropharynx reaches the upper border of C3, C2 is the more definitive landmark for the bulk of the oropharyngeal space. * **C4:** This level corresponds to the **Laryngopharynx** (Hypopharynx). The laryngopharynx extends from the upper border of the epiglottis (C3) down to the lower border of the cricoid cartilage (**C6**). **3. Clinical Pearls & High-Yield Facts:** * **Pharynx Extent:** Base of skull to **C6** (where it becomes the esophagus). * **Larynx Extent:** Typically **C3 to C6**. * **Retropharyngeal Space:** Located between the buccopharyngeal fascia and prevertebral fascia; it is a clinical "danger space" where infections can spread from the neck to the superior mediastinum. * **Killian’s Dehiscence:** A potential weak spot between the thyropharyngeus and cricopharyngeus muscles (at the C6 level), which is the site for **Zenker’s diverticulum**.

Question 1

When a large bolus of food is swallowed, the hyoid bone moves anteriorly to open the pharynx. The muscle responsible for this action is innervated by which of the following nerves?

Accepted Answer

C1 (ansa cervicalis)

Answer

Cranial Nerve IX

Answer

Pharyngeal plexus

Answer

Cranial Nerve V3

Question 2

A 45-year-old woman presents with neck pain. A CT scan reveals a tumor in the left side of her oral cavity. Following a radical neck surgical procedure for tumor removal, the patient's left shoulder droops noticeably two months postoperatively. Physical examination reveals distinct weakness in turning her head to the right and impairment of abduction of her left upper limb to the level of the shoulder. Which of the following structures was most likely injured during the radical neck surgery?

Accepted Answer

Spinal accessory nerve

Answer

Suprascapular nerve

Answer

Long thoracic nerve

Answer

The junction of spinal nerves C5 and C6 of the brachial plexus

Question 3

Into which lymph node do the lymphatics of the tonsils primarily drain?

Accepted Answer

Jugulodigastric lymph node

Answer

Jugulo-omohyoid lymph node

Answer

Submandibular lymph node

Answer

Submental lymph node

Question 4

An angiogram of a man shows an occlusion of the Costocervical Trunk. This obstruction could produce a marked decrease in the blood flow in which of the following arteries?

Accepted Answer

Deep cervical artery

Answer

Superior thoracic artery

Answer

Transverse cervical artery

Answer

Ascending cervical artery

Question 5

During surgery for squamous cell carcinoma of the neck in a 56-year-old man, the surgeon encounters profuse bleeding from a deep cervical artery. Which of the following arteries must be ligated immediately to control the bleeding?

Accepted Answer

Costocervical trunk

Answer

Transverse cervical artery

Answer

Thyrocervical trunk

Answer

Inferior thyroid artery

Question 6

The larynx extends from which vertebral level?

Accepted Answer

C3-C6

Answer

C2-C7

Answer

C1-C4

Answer

C5-C6

Question 7

Which of the following statements about the left recurrent laryngeal nerve is true?

Accepted Answer

It courses through the groove between the trachea and the esophagus.

Answer

It is a pure motor nerve.

Answer

It supplies the cricothyroid muscle.

Answer

It arises from the vagus nerve as it crosses the first part of the subclavian artery.

Question 8

At the bifurcation of the common carotid artery, where is the internal carotid artery located in relation to the external carotid artery?

Accepted Answer

Lateral to the external carotid artery.

Answer

Medial to the external carotid artery.

Answer

Posterior to the external carotid artery.

Answer

Anterior to the external carotid artery.

Question 9

During the excision of cervical lymph nodes, inadvertent injury to which nerve causes drooping of the shoulder?

Accepted Answer

Spinal accessory nerve

Answer

Supraclavicular nerve

Answer

Suprascapular nerve

Answer

Nerve to serratus anterior

Question 10

The oropharynx lies against which cervical vertebra?

Accepted Answer

C2

Answer

C1

Answer

C3

Answer

C4

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