Head and Neck Surgery Practice Questions

Q: Extraction of which isolated residual maxillary tooth offers the hazard of fracture of tuberosity?

All of the above. The **maxillary tuberosity** is the rounded eminence found on the posterior surface of the body of the maxilla. It is composed of relatively thin cortical bone and cancellous bone, making it structurally vulnerable during dental extractions. **Why "All of the above" is correct:** The risk of tuberosity fracture is highest when extracting **isolated** maxillary molars (1st, 2nd, or 3rd). When a tooth stands alone (isolated) for a long period, the surrounding alveolar bone often undergoes remodeling. Specifically, the **maxillary sinus** may undergo **pneumatization** (expansion), extending into the tuberosity area. This thins the supporting bone significantly. During extraction, the application of force (especially with forceps or elevators) can cause the weakened bone to "bridge" between the tooth and the tuberosity, leading to a fracture of the entire bony segment rather than a simple tooth delivery. * **3rd Molar:** This is the most common site for fracture due to its proximity to the posterior border of the tuberosity and the presence of divergent roots. * **1st and 2nd Molars:** While slightly less common than the 3rd molar, if these teeth are isolated and the maxillary sinus is low-lying (pneumatized), the risk of fracturing the tuberosity remains high. **High-Yield Clinical Pearls for NEET-PG:** * **Management:** If a tuberosity fracture occurs and the bone is still attached to the periosteum, it should be stabilized and the surgical site closed. If it is completely detached, it is removed, and the clinician must check for an **Oro-antral communication (OAC)**. * **Radiographic Sign:** A large, pneumatized maxillary sinus on a periapical radiograph is a warning sign for potential tuberosity fracture. * **Prevention:** Surgical extraction (sectioning the tooth) is preferred over forceful forceps extraction for isolated maxillary molars to preserve the integrity of the tuberosity.

Q: In Submandibular gland surgery, which nerve is least likely to be injured?

Inferior alveolar nerve. **Explanation:** The submandibular gland is located in the submandibular triangle, and its surgical removal (excision) requires careful dissection to avoid damaging several closely related nerves. **Why Inferior Alveolar Nerve is the Correct Answer:** The **Inferior Alveolar Nerve** is a branch of the mandibular nerve (V3) that enters the mandibular foramen to supply the lower teeth and chin. It runs deep within the bony canal of the mandible. Since it is protected by bone and is superior to the surgical field of the submandibular gland, it is **least likely** to be injured during routine gland excision. **Analysis of Incorrect Options:** * **Mandibular branch of facial nerve (Marginal Mandibular Nerve):** This is the nerve **most commonly injured** during the initial skin incision. It runs superficial to the submandibular gland fascia. To protect it, the incision is made 2 cm below the lower border of the mandible (Hayes Martin maneuver). * **Lingual Nerve:** This nerve lies deep to the gland and is connected to the submandibular ganglion. It is at risk during the ligation of the submandibular duct (Wharton’s duct), as the nerve "loops" under the duct. * **Hypoglossal Nerve:** This nerve forms the floor of the submandibular triangle (within the Lesser’s triangle). It lies deep to the tendon of the digastric muscle and the submandibular gland; it can be injured during deep dissection. **NEET-PG High-Yield Pearls:** 1. **Most common nerve injured:** Marginal Mandibular Nerve (leads to drooping of the corner of the mouth). 2. **Nerve related to the duct:** The Lingual nerve "double crosses" the submandibular duct. 3. **Incision safety:** Always make the incision 2 cm below the mandible to avoid the marginal mandibular nerve. 4. **Secretomotor pathway:** Parasympathetic fibers to the gland travel via the Chorda Tympani (branch of Facial nerve) and the Lingual nerve.

Q: Which muscle is resected in a classical neck dissection?

Sternocleidomastoid. In Radical Neck Dissection (RND), also known as **Classical Neck Dissection**, the goal is to remove all lymphatic tissue from Levels I to V on one side of the neck. To ensure complete oncological clearance, three specific non-lymphatic structures are routinely sacrificed. ### 1. Why Sternocleidomastoid (SCM) is Correct The **Sternocleidomastoid muscle** is the primary muscle resected in a classical neck dissection. It is removed to provide adequate exposure and access to the deep cervical lymph nodes (Levels II, III, and IV) that lie beneath and adjacent to it. Along with the SCM, the other two "classical" structures resected are: * **Internal Jugular Vein (IJV)** * **Spinal Accessory Nerve (SAN)** ### 2. Why Other Options are Incorrect * **A & B (Sternohyoid & Sternothyroid):** These are "strap muscles" of the neck. While they may be retracted or occasionally divided in thyroid surgeries or laryngectomies, they are not standard components of a classical neck dissection. * **D (Sternocricoid):** This is not a standard anatomical muscle of the neck; it is likely a distractor. ### 3. NEET-PG High-Yield Pearls * **Modified Radical Neck Dissection (MRND):** This is the most common variant today. It involves the same lymph node clearance as RND but **preserves** one or more of the three non-lymphatic structures (SCM, IJV, or SAN). * *Type I:* Preserves SAN. * *Type II:* Preserves SAN and IJV. * *Type III (Functional Neck Dissection):* Preserves all three (SAN, IJV, and SCM). * **Boundary:** The posterior limit of a classical neck dissection is the anterior border of the **Trapezius muscle**. * **Complication:** Resection of the Spinal Accessory Nerve leads to "Shoulder Syndrome" (shoulder pain and inability to abduct the arm above 90 degrees).

Q: Which of the following structures is preserved in a Type I modified radical neck dissection?

Spinal accessory nerve. ### Explanation The classification of neck dissections is a high-yield topic for NEET-PG. To understand the **Modified Radical Neck Dissection (MRND)**, one must first understand the **Radical Neck Dissection (RND)**, which involves the removal of lymph node levels I–V along with three non-lymphatic structures: the **Spinal Accessory Nerve (SAN)**, the **Internal Jugular Vein (IJV)**, and the **Sternocleidomastoid (SCM) muscle**. In an MRND, the same lymph node levels (I–V) are removed, but one or more of the non-lymphatic structures are preserved. The types are defined by what is **preserved**: * **Type I:** Preservation of the **Spinal Accessory Nerve** (SAN). * **Type II:** Preservation of the **SAN** and the **Internal Jugular Vein** (IJV). * **Type III:** Preservation of all three: **SAN, IJV, and SCM muscle** (also known as Functional Neck Dissection). #### Analysis of Options: * **B (Correct):** In Type I MRND, only the SAN is spared to prevent "shoulder syndrome" (shoulder drop and pain due to trapezius paralysis). * **A & D (Incorrect):** The SCM and IJV are sacrificed in Type I MRND. They are only preserved in Type III (both) or Type II (IJV). * **C (Incorrect):** Level I lymph nodes are part of the standard nodal clearance (Levels I–V) for both RND and MRND. If specific levels are spared, it is termed a "Selective Neck Dissection." ### High-Yield Clinical Pearls: * **Most common structure preserved:** The SAN is prioritized to maintain shoulder function. * **Bilateral Neck Dissection:** If both sides require surgery, at least one IJV should be preserved (Type II or III) to prevent intracranial hypertension and facial edema. * **Boundary of Level II and III:** The hyoid bone (or the bifurcation of the carotid artery) serves as the landmark. * **Erb’s Point:** The location where the SAN emerges behind the SCM, a critical landmark during surgery.

Q: All are true about alveolar osteitis except?

Main aim of the treatment is prevention of pus formation.. **Alveolar Osteitis (Dry Socket)** is a common post-extraction complication characterized by the premature loss or disintegration of the blood clot within the tooth socket. ### Explanation of Options: * **Option C (Correct Answer):** This statement is false because alveolar osteitis is **not an infection**; it is a delayed healing process due to clot lysis. Therefore, the main aim of treatment is **pain management** and promoting healing, not the prevention of pus formation (which is characteristic of osteomyelitis or an abscess). * **Option A:** This is a true statement. The condition typically manifests on the **3rd to 4th postoperative day**. It occurs because of increased **fibrinolytic activity** (plasminogen to plasmin conversion), which dissolves the clot before granulation tissue can stabilize it. * **Option B:** This is true. **Smoking** reduces local blood flow and creates negative pressure that dislodges the clot. **Oral contraceptives** increase estrogen levels, which indirectly enhances fibrinolytic activity, making females more susceptible. * **Option D:** This is true. Management is conservative. It involves gentle **irrigation** with warm saline to remove debris, followed by the placement of an **obtundent (pain-relieving) dressing**, typically containing **Zinc Oxide Eugenol** or Alveogyl. ### NEET-PG High-Yield Pearls: * **Most Common Site:** Mandibular third molar (wisdom tooth) extraction sites. * **Clinical Feature:** Severe, radiating neuralgic pain and a "foul odor" (halitosis) without systemic signs like fever or lymphadenopathy. * **Pathophysiology:** Localized fibrinolysis; the socket appears "empty" or contains grayish necrotic remnants. * **Antibiotics:** Generally **not indicated** unless the patient is immunocompromised, as the condition is non-infectious.

Question 1

Extraction of which isolated residual maxillary tooth offers the hazard of fracture of tuberosity?

Accepted Answer

All of the above

Answer

3rd molar

Answer

1st molar

Answer

2nd molar

Question 2

Which of the following statements is true regarding salivary glands?

Accepted Answer

90% of all parotid tumors are malignant.

Answer

There are more than 400 minor salivary glands.

Answer

90% of minor salivary tumors are malignant.

Answer

Superficial parotidectomy is performed for parotid tumors.

Question 3

A 62-year-old man undergoes excision of a cylindroma of the submandibular gland. He is most likely to have an injury to which of the following nerves?

Accepted Answer

Lingual nerve

Answer

Maxillary branch of the trigeminal nerve

Answer

Vagus nerve

Answer

Hypoglossal nerve

Question 4

Carcinoma of the lip is characterized by the following, except:

Accepted Answer

Lymph node metastases are common, making a radical neck dissection mandatory.

Answer

90% of lip cancers occur on the lower lip.

Answer

The most common site of origin is the vermillion border.

Answer

2 cm x 2 cm cell carcinomas can be treated by V-shaped excision and primary closure.

Question 5

In Submandibular gland surgery, which nerve is least likely to be injured?

Accepted Answer

Inferior alveolar nerve

Answer

Hypoglossal nerve

Answer

Lingual nerve

Answer

Mandibular branch of facial nerve

Question 6

Which muscle is resected in a classical neck dissection?

Accepted Answer

Sternocleidomastoid

Answer

Sternohyoid

Answer

Sternothyroid

Answer

Sternocricoid

Question 7

Incision for drainage of parotid abscess is fashioned to avoid damage to which of the following structures?

Accepted Answer

Facial nerve

Answer

Parotid duct

Answer

Retromandibular vein

Answer

Carotid artery

Question 8

Which of the following structures is preserved in a Type I modified radical neck dissection?

Accepted Answer

Spinal accessory nerve

Answer

Sternocleidomastoid muscle

Answer

Level I lymph nodes

Answer

Internal jugular vein

Question 9

All are true about alveolar osteitis except?

Accepted Answer

Main aim of the treatment is prevention of pus formation.

Answer

It is caused by fibrinolysis of the clot on the 3rd - 4th post-operative day, before formation of granulation tissue.

Answer

Incidence is higher in smokers and females on oral contraceptives.

Answer

Treatment is socket irrigation and placement of obtundent dressing.

Question 10

What is the number of plates typically required for the surgical management of a fracture involving the external oblique ridge area?

Accepted Answer

1

Answer

2

Answer

3

Answer

None

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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