Head and Neck Surgery Practice Questions

Q: Emergency tracheostomy is not indicated in

Acute severe asthma. ***Acute severe asthma*** - While life-threatening, acute severe asthma is primarily managed with **bronchodilators**, **steroids**, and potentially **non-invasive or invasive ventilation**. - **Tracheostomy** is generally reserved for situations involving upper airway obstruction that cannot be managed by other means, which is not the primary issue in asthma. *Bilateral vocal cord paralysis* - This condition can cause severe **upper airway obstruction** due to the adduction of both vocal cords. - In an emergency setting, a tracheostomy may be life-saving to bypass the obstructed larynx. *Foreign body larynx* - An obstructing **foreign body in the larynx** can lead to immediate and complete airway compromise. - If efforts like the **Heimlich maneuver** or direct laryngoscopy with removal fail, an emergency tracheostomy might be necessary. *Stridor due to laryngeal growth* - A laryngeal growth causing **stridor** indicates significant airway narrowing, which can acutely worsen and lead to respiratory distress. - In cases of severe or rapidly progressive obstruction, an **emergency tracheostomy** is needed to secure the airway below the level of the growth.

Q: Mark the FALSE statement related to tracheostomy:

Most commonly performed tracheostomy is low-tracheostomy.. ***Most commonly performed tracheostomy is low-tracheostomy.*** - This statement is **false**. The most commonly performed tracheostomy is a **mid-tracheostomy**, which involves incising the trachea at the level of the second, third, or fourth tracheal rings. - Low tracheostomy is less common due to the increased risk of complications associated with its proximity to central vessels and structures in the superior mediastinum. *Pneumothorax is a complication of mid and low tracheostomy.* - This statement is **true**. **Pneumothorax** is a recognized complication of tracheostomy, particularly with mid and low approaches, due to potential injury to the pleura. - The risk increases with lower incisions due to the proximity of the pleural domes and apex of the lungs. *In vocal cord palsy and subglottic stenosis, mid tracheostomy is planned.* - This statement is **true**. For conditions like **bilateral vocal cord palsy** or **subglottic stenosis** that cause upper airway obstruction, a **mid-tracheostomy** is the preferred approach. - This level (2nd-4th tracheal rings) provides adequate access for airway management while avoiding vital structures and the subglottic pathology. *High tracheostomy is performed above the second tracheal ring and may be needed in emergency situations.* - This statement is **true**. **High tracheostomy** involves incision above the second tracheal ring and can be performed in emergency situations requiring rapid airway access. - It may also be considered when there is pathology in the mid or lower trachea, though it carries higher risk of subglottic stenosis.

Q: One of the most important complication of tracheostomy is:

Displacement of tube. ***Displacement of tube*** - **Accidental decannulation** or displacement of the tracheostomy tube is considered one of the most serious and common complications, particularly in the immediate post-operative period. - This can lead to **loss of airway**, requiring immediate intervention to prevent severe hypoxia and potential brain injury or death. *Hemorrhage* - While hemorrhage can occur during or after tracheostomy, it is often a concern during the procedure or in the immediate postoperative period and is usually managed effectively. - Significant, life-threatening hemorrhage such as **tracheo-innominate fistula** is a rare but severe complication. *Surgical emphysema* - Surgical emphysema (subcutaneous emphysema) is a relatively common but usually benign complication that occurs when air leaks from the trachea into the subcutaneous tissues. - It typically resolves spontaneously and rarely poses a direct threat to the airway unless severe and rapidly progressive. *Recurrent laryngeal nerve palsy* - **Recurrent laryngeal nerve injury** is a rare complication of tracheostomy, as the nerve is usually well clear of the incision site in the neck. - While it can cause hoarseness or vocal cord paralysis, it typically does not present an immediate life-threatening situation or emergency comparable to airway compromise.

Q: Weber-Ferguson approach is used for?

Maxillectomy. ***Maxillectomy*** - The **Weber-Ferguson approach**, also known as the **lateral rhinotomy approach**, is a standard surgical incision used to access the midface, particularly for procedures involving the maxilla. - It provides excellent exposure for **maxillectomy**, which is the surgical removal of part or all of the maxilla, often performed for tumors of the maxillary sinus or hard palate. *Mastoidectomy* - This procedure involves the surgical removal of diseased mastoid air cells, typically performed for chronic otitis media or cholesteatoma. - The surgical approaches for mastoidectomy usually involve incisions behind the ear (**postauricular** or **endaural**), not the Weber-Ferguson incision. *Myringoplasty* - Myringoplasty is a surgical repair of a perforated eardrum (tympanic membrane). - This procedure is typically performed through the ear canal (**transcanal approach**) or a small incision behind the ear, and does not require a large facial incision like the Weber-Ferguson. *Mandibulectomy* - Mandibulectomy involves the surgical removal of part or all of the mandible (jawbone), often for malignant tumors. - Approaches for mandibulectomy typically involve **transoral**, **submandibular**, or **lip-splitting incisions**, which are distinct from the Weber-Ferguson approach and designed for lower facial access.

Q: The position adopted for tonsillectomy is also adopted for this procedure.

Tracheostomy. ***Tracheostomy*** - For a **tracheostomy**, the patient is typically positioned supine with the neck extended (often with a shoulder roll) to expose the trachea, similar to the Rose position used for tonsillectomy. - This position optimizes surgical access to the neck and upper airway, allowing for safe incision and tube placement. *Indirect laryngoscopy* - This procedure usually involves the patient sitting upright with the neck slightly flexed and the head extended, using a mirror to visualize the larynx. - It specifically avoids surgical intervention and thus does not require the same deep neck extension as tonsillectomy or tracheostomy. *Bronchoscopy* - While patient positioning may vary, bronchoscopy is primarily an endoscopic procedure that involves inserting a bronchoscope through the mouth or nose into the airways. - It does not require a surgical approach to the anterior neck and therefore does not use the tonsillectomy position. *Direct laryngoscopy* - Though it provides a direct view of the larynx, the patient is usually supine with the head extended (sniffing position) to align the oral, pharyngeal, and laryngeal axes. - While there is some neck extension, it differs from the more pronounced extension used for direct surgical access to the neck, as in tracheostomy or tonsillectomy.

Q: A 45-year-old male presents with a painless, enlarging neck mass that has been gradually increasing in size over several months. He has a history of smoking and alcohol use. What is the most likely diagnosis?

Metastatic squamous cell carcinoma of the head and neck. ***Squamous cell carcinoma of the head and neck*** - The **painless, enlarging neck mass** in a 45-year-old male with a history of **smoking and alcohol use** is highly indicative of squamous cell carcinoma [1]. - This type of cancer commonly arises in the **head and neck region**, particularly in individuals with these risk factors [1][3]. *Branchial cleft cyst* - Typically presents as a **painless, mobile mass** but usually occurs in younger individuals, not a 45-year-old male with risk factors like smoking. - Branchial cleft cysts are often **localized** and do not show the **gradual increase** in size characteristic of malignancies. *Thyroid nodule* - While thyroid nodules can present as neck masses, they are often **not painless** and usually have different risk factors that do not prominently include smoking and alcohol use. - The **patient's age** and background more strongly suggest a malignant process over a benign thyroid condition. *Benign salivary gland tumor* - Generally presents as a **painful or asymptomatic mass** but is less likely to be painless and increasing in size without associated symptoms [2]. - The **association with smoking** and the nature of the mass make malignant tumors like squamous cell carcinoma a more plausible diagnosis in this scenario.

Q: What is the most common indication for performing a tracheostomy?

Prolonged mechanical ventilation. ***Prolonged mechanical ventilation*** - Maintaining an **endotracheal tube** for an extended period carries risks like **tracheal injury**, **vocal cord damage**, and difficulty with oral intake. - A tracheostomy provides a more comfortable and stable airway for **long-term respiratory support**, facilitates weaning from the ventilator, and reduces the risk of **ventilator-associated pneumonia**. *Severe obstructive sleep apnea* - While tracheostomy can effectively treat severe OSA by bypassing the upper airway obstruction, it is generally considered a **last resort** after less invasive treatments have failed. - The most common initial treatments for OSA include **CPAP**, weight loss, and oral appliances. *Tracheal stenosis* - Tracheal stenosis itself is a **structural narrowing** of the trachea that may or may not require tracheostomy, depending on its severity and location. - While a tracheostomy can bypass a severe stenosis, surgical repair of the trachea is often the definitive treatment for **severe tracheal stenosis**. *Vocal cord paralysis* - Unilateral vocal cord paralysis typically causes **hoarseness** and may not always necessitate a tracheostomy. - Bilateral vocal cord paralysis can lead to **airway obstruction**, but intervention usually involves vocal cord lateralization procedures or, in severe cases, a tracheostomy for airway patency.

Q: What surgical procedure is commonly associated with the Weber-Ferguson approach?

Surgical removal of the maxilla. ***Surgical removal of the maxilla*** - The **Weber-Ferguson approach** is a classic surgical incision used to access the midface, particularly for **maxillectomy**. - This approach provides excellent exposure for resecting tumors of the **maxilla**, nasal cavity, and paranasal sinuses. *Surgical removal of the mastoid process* - Removal of the mastoid process, known as **mastoidectomy**, is typically performed via a **postauricular incision** or an endaural approach. - This procedure is used for conditions like chronic otitis media or mastoiditis, and is unrelated to the Weber-Ferguson approach. *Repair of the eardrum* - **Tympanoplasty** is the surgical repair of the eardrum and is usually performed through an **endaural** or **postauricular incision**. - This procedure targets the middle ear and does not require the extensive midfacial access provided by the Weber-Ferguson approach. *Surgical removal of the mandible* - **Mandibulectomy** involves the surgical removal of part or all of the mandible and can be approached externally through incisions such as the **Risdon incision** or intraorally. - The Weber-Ferguson approach specifically targets the **upper jaw** and midface, not the lower jaw or mandible.

Q: Patient presents with a mass in the parapharyngeal region pushing the carotid artery backwards; the likely cause is?

Carotid body tumor. ***Carotid body tumor*** - Carotid body tumors are **paragangliomas** that typically arise at the **carotid bifurcation** and characteristically displace the **carotid artery posteriorly and laterally**. - They are often palpable as a non-tender mass in the anterior neck and can cause symptoms related to **compression of surrounding structures**. - Classic imaging finding is the **"Lyre sign"** showing splaying of the internal and external carotid arteries. *Lymph node enlargement* - Enlarged lymph nodes (e.g., due to infection, inflammation, or malignancy) are typically located **anterior or lateral to the great vessels** and do not characteristically displace the carotid artery in a posterior direction. - They usually cause **anterior or medial displacement** of the carotid vessels. *Sternocleidomastoid tumor* - Tumors of the sternocleidomastoid muscle (e.g., fibromatosis colli in infants, rhabdomyosarcoma) originate within the muscle itself, causing a mass **within the muscle belly**. - These tumors would not typically cause the **posterior displacement of the carotid artery** as described since they are extrinsic to the great vessels. *Deep lobe parotid tumor* - Deep lobe parotid tumors (e.g., pleomorphic adenoma) can present as parapharyngeal masses but typically cause **medial and anterior displacement** of the carotid vessels. - They arise from the **parapharyngeal extension of the parotid gland** and push the carotid space structures differently than carotid body tumors.

Question 1

Emergency tracheostomy is not indicated in

Accepted Answer

Acute severe asthma

Answer

Bilateral vocal cord paralysis

Answer

Foreign body larynx

Answer

Stridor due to laryngeal growth

Question 2

Mark the FALSE statement related to tracheostomy:

Accepted Answer

Most commonly performed tracheostomy is low-tracheostomy.

Answer

Pneumothorax is a complication of mid and low tracheostomy.

Answer

In vocal cord palsy and subglottic stenosis, mid tracheostomy is planned.

Answer

High tracheostomy is performed above the second tracheal ring and may be needed in emergency situations.

Question 3

One of the most important complication of tracheostomy is:

Accepted Answer

Displacement of tube

Answer

Hemorrhage

Answer

Surgical emphysema

Answer

Recurrent laryngeal nerve palsy

Question 4

Weber-Ferguson approach is used for?

Accepted Answer

Maxillectomy

Answer

Mastoidectomy

Answer

Myringoplasty

Answer

Mandibulectomy

Question 5

The position adopted for tonsillectomy is also adopted for this procedure.

Accepted Answer

Tracheostomy

Answer

Indirect laryngoscopy

Answer

Bronchoscopy

Answer

Direct laryngoscopy

Question 6

A 45-year-old male presents with a painless, enlarging neck mass that has been gradually increasing in size over several months. He has a history of smoking and alcohol use. What is the most likely diagnosis?

Accepted Answer

Metastatic squamous cell carcinoma of the head and neck

Answer

Branchial cleft cyst

Answer

Thyroid nodule

Answer

Benign salivary gland tumor

Question 7

What is the most common indication for performing a tracheostomy?

Accepted Answer

Prolonged mechanical ventilation

Answer

Severe obstructive sleep apnea

Answer

Tracheal stenosis

Answer

Vocal cord paralysis

Question 8

Which of the following is a common indication for performing a tracheostomy?

Accepted Answer

Prolonged mechanical ventilation requiring intubation for more than 7-10 days

Answer

Severe respiratory distress due to tracheal stenosis

Answer

Severe airway obstruction due to a foreign body

Answer

Chronic obstructive pulmonary disease (COPD) exacerbation

Question 9

What surgical procedure is commonly associated with the Weber-Ferguson approach?

Accepted Answer

Surgical removal of the maxilla

Answer

Surgical removal of the mastoid process

Answer

Repair of the eardrum

Answer

Surgical removal of the mandible

Question 10

Patient presents with a mass in the parapharyngeal region pushing the carotid artery backwards; the likely cause is?

Accepted Answer

Carotid body tumor

Answer

Lymph node enlargement

Answer

Sternocleidomastoid tumor

Answer

Deep lobe parotid tumor

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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