Neck Practice Questions

Q: Superior margin of infant's larynx is at the level of

Cervical spine C2. ***Cervical spine C2*** - In infants, the **larynx** is positioned relatively high in the neck, with its superior margin typically found at the level of the **second cervical vertebra (C2)**. - This high laryngeal position is crucial for **coordinated sucking and breathing** in infants. *Cervical spine C1* - The superior margin of the larynx is generally lower than **C1** in infants. - **C1** (atlas) is the uppermost cervical vertebra, and the larynx typically extends below this level. *Cervical spine C4* - In adults, the superior margin of the larynx descends to around the level of **C4**. - This option represents the **adult laryngeal position**, which is significantly lower than in infants. *Cervical spine C3* - While the larynx is relatively high in infants, its superior margin typically sits slightly above **C3**. - **C3** usually corresponds to the body of the hyoid bone, with the top of the larynx being around C2.

Q: Which of the following cartilages has signet ring shape?

Cricoid. ***Cricoid*** - The **cricoid cartilage** is the only complete ring of cartilage in the airway, forming the base of the larynx. - Its unique shape, with a narrow anterior arch and a broad posterior lamina, resembles a **signet ring**. *Cuneiform* - **Cuneiform cartilages** are small, rod-shaped cartilages found within the aryepiglottic folds. - They provide support to the folds but do not have a signet ring shape. *Thyroid* - The **thyroid cartilage** is the largest laryngeal cartilage and is shield-shaped, commonly known as the Adam's apple. - It is an incomplete ring posteriorly and does not have a signet ring appearance. *Arytenoid* - **Arytenoid cartilages** are paired pyramidal cartilages that articulate with the cricoid cartilage. - They are crucial for vocal cord movement but are not ring-shaped.

Q: In doing phrenic nerve block, it is best to infiltrate

Posterior border of sternomastoid. Posterior border of sternomastoid - The phrenic nerve (C3-C5) descends on the anterior surface of the scalenus anterior muscle through the neck. - To block the phrenic nerve as it emerges from the brachial plexus roots, local anesthetic is ideally infiltrated at the posterior border of the sternomastoid muscle at the level of the cricoid cartilage (C6 vertebral level). Scalenus anterior - While the phrenic nerve rests on the anterior surface of the scalenus anterior, infiltrating this muscle directly might not be as effective for a complete block, as the nerve is relatively superficial at the posterior border of the sternomastoid. - Infiltration within the scalenus anterior could potentially lead to a less targeted block or hit other structures within the muscle. Scalenus posterior - The scalenus posterior muscle is located deeper and more laterally in the neck compared to the scalenus anterior. - The phrenic nerve does not have a direct anatomical relationship with the scalenus posterior that would make this an optimal site for a block. Anterior border of sternomastoid - The anterior border of the sternomastoid muscle provides an anatomical landmark for other neck structures, but the phrenic nerve is not readily accessible for blockade at this specific location. - Infiltrating here would be too anterior and medial to where the phrenic nerve emerges from the brachial plexus components.

Q: Submandibular nodes are classified as

Level 1B neck nodes. ***Level 1B neck nodes*** - The **submandibular nodes** are located anterior to the posterior belly of the digastric muscle and lateral to the anterior belly of the digastric muscle, placing them within **Level 1B** of the neck lymph node classification [1]. - This level primarily drains the oral cavity, face, and submandibular gland [1]. *Level III neck nodes* - **Level III** nodes are the middle jugular nodes, located between the level of the hyoid bone and the cricoid cartilage. - These nodes are typically found along the **internal jugular vein** and drain structures such as the larynx, hypopharynx, and thyroid. *Level II neck nodes* - **Level II** nodes, or upper jugular nodes, are located from the skull base to the inferior border of the hyoid bone, along the internal jugular vein. - This level is further divided into Level IIA (anterior to the spinal accessory nerve) and Level IIB (posterior to the spinal accessory nerve) and drains structures like the nasopharynx, oropharynx, and parotid gland. *Level 1 A neck nodes* - **Level 1A** nodes refer to the **submental nodes**, which are located between the anterior bellies of the digastric muscles [1]. - These nodes primarily drain the central lower lip, floor of the mouth, anterior tongue, and chin [1].

Q: During a knife fight, a person is injured in the neck region and presents with weakness in raising the right arm above the head. On further examination, winging of the right scapula is noted. The injury has damaged:

Spinal accessory nerve. ***Spinal accessory nerve*** - **Weakness in raising the arm above the head** and **winging of the scapula** are characteristic signs of **trapezius muscle dysfunction**, which is supplied by the **spinal accessory nerve (CN XI)**. - The trapezius is essential for **upward rotation of the scapula** during overhead arm abduction (>90°). - Injury to the spinal accessory nerve in the posterior triangle of the neck causes **lateral winging** of the scapula (inferior angle moves laterally), which is most prominent when attempting to raise the arm overhead. - The combination of **scapular winging** + **inability to abduct the arm above horizontal** is pathognomonic for trapezius paralysis. *Long thoracic nerve of Bell* - Damage to the long thoracic nerve causes paralysis of the **serratus anterior muscle**, leading to **medial winging** of the scapula (medial border lifts away from chest wall). - While scapular winging occurs, it is most prominent during **forward flexion** or **pushing movements** (e.g., push-ups, pushing against a wall), not specifically when raising the arm overhead. - Patients can usually still abduct the arm overhead, though with altered scapular mechanics. *Dorsal scapular nerve* - The dorsal scapular nerve innervates the **rhomboid major and minor muscles** and the **levator scapulae**. - Injury primarily causes difficulty **retracting the scapula** (pulling shoulders back) and weakness in shoulder elevation. - Does **not** cause scapular winging or significant weakness in overhead arm movement. *Suprascapular nerve* - The suprascapular nerve innervates the **supraspinatus** and **infraspinatus muscles**. - Damage causes weakness of shoulder **initiation of abduction** (first 15° by supraspinatus) and **external rotation** (infraspinatus). - Does **not** cause scapular winging, as these are rotator cuff muscles, not scapular stabilizers.

Q: Nodes of Rouviere -

Retropharyngeal node. ***Retropharyngeal node*** - The **Node of Rouviere** is specifically the uppermost lymph node in the **retropharyngeal chain**. - It is clinically important as it serves as the primary drainage site for the **nasopharynx**. *Adenoids* - **Adenoids** (pharyngeal tonsils) are lymphoid tissue located in the **nasopharynx**, but they are a diffuse collection of tissue, not a specific single lymph node. - While they are part of Waldeyer's ring and involved in immune function, they are distinct from the individual retropharyngeal lymph nodes. *Parapharyngeal node* - **Parapharyngeal nodes** are located in the **parapharyngeal space**, distinct from the more posterior retropharyngeal space. - They drain structures such as the oral cavity, oropharynx, and parotid gland, but are not synonymous with the Node of Rouviere. *None of the options* - This option is incorrect because **"Retropharyngeal node"** correctly identifies the Node of Rouviere.

Q: What is the narrowest part of the infant's respiratory tract?

Subglottis. ***Subglottis*** - In infants and young children, the **cricoid cartilage** (forming the subglottis) is the narrowest and least distensible portion of the airway. - This anatomical feature makes the subglottis particularly susceptible to **edema** and obstruction during inflammation or infection, leading to conditions like **croup**. *Glottis* - The glottis is the narrowest part of the adult airway, but not the infant airway. - It consists of the **vocal cords** and the space between them, playing a crucial role in phonation. *Carina* - The carina is the point where the trachea divides into the two main bronchi. - While a significant anatomical landmark, it is not the narrowest part of the respiratory tract in infants or adults. *Epiglottis* - The epiglottis is a cartilaginous flap that prevents food from entering the trachea during swallowing. - While important for airway protection, it is not the narrowest part of the infant's respiratory tract.

Q: Which of the following is not a suprahyoid space?

Anterior visceral space. ***Anterior visceral space*** - The **anterior visceral space** is located primarily inferior to the hyoid bone, encompassing structures like the **thyroid gland** and **trachea**. - Its anatomical position makes it an **infrahyoid space**, rather than a suprahyoid space. *Peritonsillar space* - The **peritonsillar space** surrounds the palatine tonsils and is located superior to the hyoid bone. - Infections like **peritonsillar abscesses** occur within this suprahyoid space. *Masticator space* - The **masticator space** contains the muscles of mastication (masseter, temporalis, medial and lateral pterygoids) and is entirely above the hyoid bone. - It is a significant **suprahyoid space** prone to infections and tumors arising from jaw structures. *Parapharyngeal space* - The **parapharyngeal space** is a critical fascial space extending from the skull base to the hyoid bone. - It is classified as a **suprahyoid space** due to its predominant location superior to the hyoid.

Q: Delphian's nodes are not related to which of the following? (ENT)

Posterior triangle. ***Posterior triangle*** - **Delphian nodes** are part of the deep cervical lymph node chain and are named for their clinical significance in detecting subclinical disease, typically related to recurrent laryngeal cancer. - The posterior triangle of the neck contains lymph nodes, but they are not specifically known as Delphian nodes; these nodes drain different regions and are generally not indicative of laryngeal involvement. *Retropharyngeal* - The **retropharyngeal lymph nodes** are located behind the pharynx and drain the posterior nasal cavity, paranasal sinuses, nasopharynx, and oropharynx. - While they are part of the head and neck lymphatics, they are distinct from Delphian nodes, which are more anterior and midline. *Upper deep cervical* - The **upper deep cervical lymph nodes** are a primary drainage pathway for many head and neck structures, including the larynx. - While Delphian nodes are distinct, their close proximity and shared drainage patterns mean they are functionally related to the larger deep cervical chain in assessing laryngeal cancer spread. *Pre-laryngeal* - **Delphian nodes**, also known as cricothyroid or pre-laryngeal nodes, are located in the prelaryngeal space, anterior to the cricothyroid membrane [1]. - Their involvement is highly suspicious for thyroid or laryngeal carcinoma, making them crucial for early detection of advanced disease [1].

Q: Commonest site of branchial cyst:

Upper 1/3rd of sternomastoid on anterior border. ***Upper 1/3rd of sternomastoid on anterior border*** - The **second branchial cleft** anomaly (accounting for 90-95% of all branchial cysts) commonly develops along the **anterior border of the sternocleidomastoid muscle** in the upper third of the neck, at the junction of upper and middle thirds [2]. - This location corresponds to the embryological remnants of the **second branchial pouch and cleft**. - The cyst typically presents as a smooth, fluctuant, non-tender mass that may become infected. *Upper 1/3rd of sternomastoid on posterior border* - This location is less common for branchial cysts, which typically originate along the anterior border of the sternocleidomastoid. - Cysts in the posterior triangle of the neck are more often associated with other conditions, such as **cystic hygroma** or lymph node pathology [1]. *Lower 1/3rd of sternomastoid on posterior border* - Branchial cysts usually occur in the **upper third** to junction of upper and middle thirds of the neck due to the developmental anatomy of the **second branchial arch and pouch**. - Cysts found in the lower posterior aspect of the neck are less likely to be branchial cysts. *Lower 1/3rd of sternomastoid on anterior border* - While along the anterior border, branchial cysts are predominantly found in the **upper third** or at the junction of upper and middle thirds of the sternocleidomastoid muscle. - Lesions in this lower, anterior position might suggest alternative diagnoses such as a **thyroglossal duct cyst** if midline, or other cervical masses like **thyroid nodules** or lymphadenopathy.

Question 1

Superior margin of infant's larynx is at the level of

Accepted Answer

Cervical spine C2

Answer

Cervical spine C1

Answer

Cervical spine C4

Answer

Cervical spine C3

Question 2

Which of the following cartilages has signet ring shape?

Accepted Answer

Cricoid

Answer

Cuneiform

Answer

Thyroid

Answer

Arytenoid

Question 3

In doing phrenic nerve block, it is best to infiltrate

Accepted Answer

Posterior border of sternomastoid

Answer

Scalenus anterior

Answer

Scalenus posterior

Answer

Anterior border of sternomastoid

Question 4

Submandibular nodes are classified as

Accepted Answer

Level 1B neck nodes

Answer

Level III neck nodes

Answer

Level II neck nodes

Answer

Level 1A neck nodes

Question 5

During a knife fight, a person is injured in the neck region and presents with weakness in raising the right arm above the head. On further examination, winging of the right scapula is noted. The injury has damaged:

Accepted Answer

Spinal accessory nerve

Answer

Long thoracic nerve of Bell

Answer

Dorsal scapular nerve

Answer

Suprascapular nerve

Question 6

Nodes of Rouviere -

Accepted Answer

Retropharyngeal node

Answer

Adenoids

Answer

Parapharyngeal node

Answer

None of the options

Question 7

What is the narrowest part of the infant's respiratory tract?

Accepted Answer

Subglottis

Answer

Glottis

Answer

Carina

Answer

Epiglottis

Question 8

Which of the following is not a suprahyoid space?

Accepted Answer

Anterior visceral space

Answer

Peritonsillar space

Answer

Masticator space

Answer

Parapharyngeal space

Question 9

Delphian's nodes are not related to which of the following? (ENT)

Accepted Answer

Posterior triangle

Answer

Retropharyngeal

Answer

Upper deep cervical

Answer

Pre-laryngeal

Question 10

Commonest site of branchial cyst:

Accepted Answer

Upper 1/3rd of sternomastoid on anterior border

Answer

Upper 1/3rd of sternomastoid on posterior border

Answer

Lower 1/3rd of sternomastoid on posterior border

Answer

Lower 1/3rd of sternomastoid on anterior border

Neck — MCQs

Neck — MCQs

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