Head and Neck Surgery Practice Questions

Q: A 58-year-old man presents with a 3-month history of hoarseness and occasional aspiration while drinking liquids following a left-sided thyroid lobectomy. He denies stridor or dyspnoea at rest. His laryngoscopic image taken during phonation is shown (Image 1). Which nerve injury is responsible for the findings seen in this image?

A. Left recurrent laryngeal nerve. ***A. Left recurrent laryngeal nerve*** - The clinical history of **hoarseness** and **aspiration** following thyroid surgery, combined with a vocal cord fixed in the **paramedian position**, is a classic presentation of **unilateral recurrent laryngeal nerve (RLN)** injury. - Injury to the RLN results in paralysis of all intrinsic muscles of the larynx except the cricothyroid, leading to an inability to **abduct** or **adduct** the affected cord and a failure of **glottic closure** during phonation. *B. Left superior laryngeal nerve, external branch* - This nerve supplies the **cricothyroid muscle**, which is responsible for tensing the vocal cords to increase **vocal pitch**. - Isolated injury typically causes a **weak, breathy voice** or inability to produce high-pitched sounds, but the vocal cord remains **mobile** and does not result in paramedian fixation. *C. Left superior laryngeal nerve, internal branch* - This branch provides **sensory innervation** to the laryngeal mucosa above the level of the vocal folds. - While injury can lead to loss of the **cough reflex** and increased aspiration risk, it does not cause **motor paralysis** or hoarseness associated with vocal cord immobility. *D. Left vagus nerve at the level of the jugular foramen* - A high-level vagal lesion would result in loss of function for both the **recurrent laryngeal** and **superior laryngeal** nerves, typically placing the cord in a **cadaveric (abducted) position**. - Such a lesion would also involve **pharyngeal and palatal paralysis**, leading to symptoms like nasal regurgitation, which are not described in this patient.

Q: Which structure is damaged in a high tracheostomy?

First tracheal ring. **Explanation:** In surgical practice, tracheostomy is categorized based on its relationship to the **thyroid isthmus**, which typically overlies the 2nd, 3rd, and 4th tracheal rings. 1. **Why Option C is Correct:** A **high tracheostomy** is performed above the level of the thyroid isthmus, specifically involving the **1st tracheal ring**. This procedure is strictly contraindicated in elective cases because damage to the 1st tracheal ring or the cricoid cartilage can lead to **perichondritis** and subsequent **subglottic stenosis**, a debilitating long-term complication. 2. **Why other options are incorrect:** * **Thyroid isthmus (A):** This is the landmark used to define the level. In a mid-tracheostomy (the preferred elective site), the isthmus is either retracted or divided to access the 2nd and 3rd rings. * **Aortic knuckle (B):** This is a mediastinal structure located far inferior to the tracheostomy site. It is only at risk in "low tracheostomies" (below the 4th ring) in patients with a high-riding innominate artery or in children. * **Recurrent laryngeal nerve (D):** These nerves run in the tracheoesophageal groove. While they can be injured during lateral dissection, they are not the primary structure damaged by the "high" placement of the tracheal opening itself. **Clinical Pearls for NEET-PG:** * **Ideal Site:** The 2nd and 3rd tracheal rings (Mid-tracheostomy) are the safest for elective procedures. * **Emergency Airway:** If an immediate airway is needed and a standard tracheostomy is too slow, **Cricothyroidotomy** is the procedure of choice. * **Most Common Complication:** Immediate (Hemorrhage); Late (Tracheal stenosis).

Q: Which one of the following is the most common tumor to produce metastasis to cervical lymph nodes?

Nasopharyngeal carcinoma. **Explanation:** The correct answer is **Nasopharyngeal Carcinoma (NPC)**. This is due to the rich submucosal lymphatic network of the nasopharynx and the fact that NPC often remains clinically silent in its early stages. Consequently, **75–90% of patients** present with cervical lymphadenopathy at the time of diagnosis. It is the most common primary site for an "unknown primary" presenting as a neck mass. Metastasis is often bilateral and typically involves Level II, III, and V (posterior triangle) nodes. **Analysis of Options:** * **Glottic Carcinoma:** The vocal cords have **sparse to no lymphatic drainage**. Therefore, glottic cancer rarely metastasizes to the neck in early stages (T1/T2), making it the least likely among the options to present with nodal spread. * **Carcinoma Base of Tongue:** While this area is rich in lymphatics and has a high rate of nodal metastasis (approx. 60–70%), it is statistically less frequent than Nasopharyngeal Carcinoma. * **Carcinoma Lip:** This typically spreads to Level I (submental/submandibular) nodes. It generally has a better prognosis and a lower rate of early metastasis (approx. 10%) compared to oropharyngeal or nasopharyngeal sites. **High-Yield Clinical Pearls for NEET-PG:** * **Rouviere’s Node:** The most superior lateral retropharyngeal node, often the first site of spread in NPC. * **Troisier’s Sign:** Enlargement of the left supraclavicular node (Virchow’s node), usually indicating intra-abdominal malignancy (e.g., Gastric CA), not primary head and neck CA. * **EBV Association:** Nasopharyngeal carcinoma (specifically Type II and III) is strongly associated with the **Epstein-Barr Virus**. * **Rule of 80:** In non-thyroid neck masses in adults, 80% are neoplastic, and of those, 80% are malignant (mostly metastatic Squamous Cell Carcinoma).

Q: Which of the following statements regarding branchial anomalies is true?

Most commonly, the second branchial arch is involved.. **Explanation:** Branchial anomalies arise from the failure of the branchial apparatus (clefts, arches, and pouches) to involute during embryonic development. **1. Why Option A is Correct:** The **second branchial arch** (specifically the second branchial cleft) is involved in approximately **95% of all branchial anomalies**. These typically present as a cyst or sinus located along the anterior border of the sternocleidomastoid muscle, at the junction of its upper and middle thirds. **2. Why the Other Options are Incorrect:** * **Option B:** **Branchial cysts** are actually **more common** than branchial sinuses or fistulae. They often present in late childhood or early adulthood, frequently following an upper respiratory tract infection. * **Option C:** First arch anomalies **do occur**, though they are rare (approx. 1-8%). They are classified into Type I (periauricular) and Type II (perimandibular) and are closely related to the external auditory canal and the facial nerve. * **Option D:** **External draining sinuses** (opening on the skin) are more common than internal draining sinuses (opening into the pharynx). **High-Yield NEET-PG Pearls:** * **Location of 2nd Cleft Cyst:** Found deep to the platysma, anterior to the SCM, and **between the internal and external carotid arteries** (bifurcation). * **Internal Opening:** A second branchial fistula typically opens internally in the **tonsillar fossa**. * **Third Cleft Anomalies:** Rare; the internal opening is in the **pyriform sinus**, and they are often associated with recurrent thyroiditis. * **Fourth Cleft Anomalies:** Extremely rare; they typically loop around the aorta (left) or subclavian artery (right).

Q: Which of the following comprises Level V cervical nodes?

Posterior triangle nodes. The cervical lymph node classification system (Memorial Sloan-Kettering Cancer Center) divides the neck into six levels, which is a high-yield topic for NEET-PG. ### **Explanation** **Level V** refers to the **Posterior Triangle nodes**. These are bounded anteriorly by the posterior border of the sternocleidomastoid (SCM) muscle, posteriorly by the anterior border of the trapezius muscle, and inferiorly by the clavicle. This level includes the spinal accessory (CN XI) nodes, transverse cervical nodes, and supraclavicular nodes. ### **Analysis of Options** * **Option A (Upper jugular nodes):** These comprise **Level II**. They extend from the skull base to the level of the hyoid bone (or carotid bifurcation). * **Option B (Middle jugular nodes):** These comprise **Level III**. They extend from the hyoid bone to the lower border of the cricoid cartilage (or omohyoid muscle). * **Option C (Lower jugular nodes):** These comprise **Level IV**. They extend from the cricoid cartilage down to the clavicle. ### **High-Yield Clinical Pearls** * **Level I:** Submental (Ia) and Submandibular (Ib) nodes. * **Level VI:** Anterior compartment nodes (pre-laryngeal, pre-tracheal, and para-tracheal). * **Level VII:** Superior mediastinal nodes (below the suprasternal notch). * **Boundary Marker:** The **omohyoid muscle** is the surgical landmark that separates Level III from Level IV. * **Level V Subdivisions:** Level Va (above the cricoid, contains spinal accessory nodes) and Level Vb (below the cricoid, contains transverse cervical and supraclavicular nodes).

Question 1

A 38-year-old man presents with a 6-year history of foul-smelling, painless unilateral ear discharge and progressive conductive hearing loss. He denies fever or vertigo. Otoscopy is performed and the image is shown (Image 1). Which of the following best explains the mechanism by which this condition causes progressive hearing loss?

Accepted Answer

A. Enzymatic osteolysis driven by keratinocyte-derived collagenases eroding the ossicular chain

Answer

B. Fibrous ankylosis of the stapes footplate to the oval window from repeated mucosal inflammation

Answer

C. Endolymphatic hydrops causing fluctuating sensorineural loss superimposed on middle ear effusion

Answer

D. Granulation tissue obstructing the Eustachian tube orifice leading to chronic negative middle ear pressure

Question 2

A 58-year-old man presents with a 3-month history of hoarseness and occasional aspiration while drinking liquids following a left-sided thyroid lobectomy. He denies stridor or dyspnoea at rest. His laryngoscopic image taken during phonation is shown (Image 1). Which nerve injury is responsible for the findings seen in this image?

Accepted Answer

A. Left recurrent laryngeal nerve

Answer

B. Left superior laryngeal nerve, external branch

Answer

C. Left superior laryngeal nerve, internal branch

Answer

D. Left vagus nerve at the level of the jugular foramen

Question 3

A patient presents with a tumor at the base of the tongue. What is the treatment of choice?

Accepted Answer

Wide local excision plus cervical lymph node dissection

Answer

Wide local excision

Answer

Wide local excision plus radiotherapy

Answer

Hemiglossectomy

Question 4

Which structure is damaged in a high tracheostomy?

Accepted Answer

First tracheal ring

Answer

Thyroid isthmus

Answer

Aortic knuckle

Answer

Recurrent laryngeal nerve

Question 5

Secondaries in the neck with no obvious primary malignancy is most often due to which of the following?

Accepted Answer

Carcinoma of the Nasopharynx

Answer

Carcinoma of the Stomach

Answer

Carcinoma of the Larynx

Answer

Carcinoma of the Thyroid

Question 6

Which one of the following is the most common tumor to produce metastasis to cervical lymph nodes?

Accepted Answer

Nasopharyngeal carcinoma

Answer

Glottic carcinoma

Answer

Carcinoma base of tongue

Answer

Carcinoma lip

Question 7

Which of the following is/are a contraindication for supraglottic laryngectomy?

Accepted Answer

Poor pulmonary reserve, Tumor involving pre-epiglottic space, Vocal cord fixation, Postcricoid area extension

Answer

Poor pulmonary reserve, Tumor involving pyriform sinus, Tumor involving pre-epiglottic space, Vocal cord fixation

Answer

Tumor involving pyriform sinus, Tumor involving pre-epiglottic space, Vocal cord fixation, Postcricoid area extension

Answer

Poor pulmonary reserve, Vocal cord fixation, Postcricoid area extension

Question 8

A 22-year-old woman underwent tracheostomy during hospitalization following a major motor vehicle accident. Five days post-tracheostomy, she develops minor bleeding around the site. What is the most appropriate immediate management?

Accepted Answer

Perform bronchoscopic evaluation of the trachea at the bedside.

Answer

Remove the tracheostomy at the bedside.

Answer

Exchange the tracheostomy at the bedside.

Answer

Exchange the tracheostomy in the operating room.

Question 9

Which of the following statements regarding branchial anomalies is true?

Accepted Answer

Most commonly, the second branchial arch is involved.

Answer

Branchial cysts are less common than branchial sinuses.

Answer

First arch branchial anomalies are never seen.

Answer

Internal draining sinuses are the most common type.

Question 10

Which of the following comprises Level V cervical nodes?

Accepted Answer

Posterior triangle nodes

Answer

Upper jugular nodes

Answer

Middle jugular nodes

Answer

Lower jugular nodes

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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