Head and Neck Surgery Practice Questions

Q: If retromolar pad and tuberosity contact, what should be done?

Surgical reduction of tuberosity. **Explanation:** The goal of pre-prosthetic surgery is to create an optimal environment for denture stability, retention, and support. The **retromolar pad** (mandible) and the **maxillary tuberosity** (maxilla) are critical landmarks for denture extension. **1. Why Option A is Correct:** For a complete denture to be successful, there must be adequate **inter-arch distance** (inter-ridge space) to accommodate the denture bases and artificial teeth. If the maxillary tuberosity and the retromolar pad are in contact (or have insufficient clearance), there is no room for the denture material. **Surgical reduction of the tuberosity** (either bony or fibrous tissue) is the standard procedure to create the necessary vertical space without compromising the mandibular anatomy, which is often more prone to resorption. **2. Why Other Options are Wrong:** * **Option B:** The retromolar pad is a primary stress-bearing area and provides a peripheral seal for the mandibular denture. Failing to extend the denture here leads to poor stability and rapid ridge resorption. * **Option C:** Denture fabrication is possible, but only after corrective surgery to create the required restorative space. * **Option D:** Contact between these structures prevents the patient from closing into centric occlusion with the dentures in place, leading to constant displacement and pain. **Clinical Pearls for NEET-PG:** * **Inter-arch distance:** Ideally, 10–12 mm of space is required for both arches. * **Retromolar Pad:** It contains glandular tissue, fibers of the buccinator, and the pterygomandibular raphe; it does not resorb and serves as a key landmark for the occlusal plane. * **Pendulous Tuberosity:** Often caused by fibrous hyperplasia; if it interferes with the "Hamular Notch" seal or vertical space, surgical excision (Elliptical incision) is indicated.

Q: A 2-year-old child presents with a brilliantly translucent swelling in the neck region. What is the most likely diagnosis?

Cystic hygroma. **Explanation:** The correct answer is **Cystic hygroma**. The clinical presentation of a **brilliantly translucent** swelling in a child’s neck is a classic hallmark of this condition. **1. Why Cystic Hygroma is Correct:** Cystic hygroma (also known as macrocystic lymphatic malformation) is a congenital malformation of the lymphatic system where lymph vessels fail to connect with the venous system. This results in large, fluid-filled sacs. Because these cysts contain clear, straw-colored lymph and have very thin walls, they demonstrate **brilliant transillumination**. They are most commonly found in the posterior triangle of the neck and are typically present at birth or manifest by age two. **2. Why Other Options are Incorrect:** * **Lipoma:** While soft and painless, lipomas are composed of fat and are **not translucent**. They are also relatively rare in early childhood. * **Teratoma:** These are solid or mixed germ cell tumors. Due to their dense, multi-tissue composition (hair, teeth, muscle), they are **opaque** on transillumination. * **Thyroglossal Cyst:** These occur in the midline of the neck and move with protrusion of the tongue. While they are cystic, they are usually **not translucent** because they contain mucoid material or debris. **Clinical Pearls for NEET-PG:** * **Pathognomonic Sign:** "Brilliant transillumination" is the single most important clue for Cystic Hygroma. * **Association:** Frequently associated with chromosomal anomalies like **Turner Syndrome** (45, XO) and Down Syndrome. * **Complications:** Sudden increase in size usually indicates **hemorrhage** into the cyst or infection. * **Treatment:** Surgical excision is the gold standard; however, **Sclerotherapy** (using OK-432 or Bleomycin) is an effective non-surgical alternative.

Q: A patient has a 3 cm mass over the lower lip and a single lymph node measuring 3 cm was present on the contralateral side. What is the TNM staging of this lip carcinoma?

T2 N2c. ### **Explanation** The staging of Lip and Oral Cavity Carcinoma follows the AJCC (8th Edition) TNM classification. **1. T-Staging (Tumor Size):** * **T1:** Tumor ≤ 2 cm in greatest dimension. * **T2:** Tumor > 2 cm but ≤ 4 cm. * **T3:** Tumor > 4 cm. * In this case, the mass is **3 cm**, which classifies it as **T2**. **2. N-Staging (Nodal Involvement):** * **N1:** Single ipsilateral node ≤ 3 cm. * **N2a:** Single ipsilateral node > 3 cm but ≤ 6 cm. * **N2b:** Multiple ipsilateral nodes, none > 6 cm. * **N2c:** Bilateral or **contralateral** lymph nodes, none > 6 cm. * Since the patient has a **single 3 cm node on the contralateral side**, it is classified as **N2c**. Combining these gives the stage **T2 N2c**. --- ### **Why Incorrect Options are Wrong:** * **Option A (T1 N2a):** Incorrect because the tumor is > 2 cm (T2) and the node is contralateral (N2c), not ipsilateral (N2a). * **Option B (T2 N2b):** While the T-stage is correct, N2b refers to multiple ipsilateral nodes. Contralateral involvement automatically upgrades the N-stage to N2c. * **Option D (T1 N2b):** Incorrect on both counts; the size is T2 and the nodal distribution is N2c. --- ### **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Site:** The lower lip is the most common site for lip cancer (usually Squamous Cell Carcinoma) due to sun exposure. * **Prognosis:** Lip cancer has a better prognosis than intraoral SCC because it is detected earlier. * **AJCC 8th Ed. Update:** For oral cavity (not lip), **Depth of Invasion (DOI)** is now a critical component of T-staging (T1 ≤ 5mm, T2 > 5mm to 10mm, T3 > 10mm). * **N-Stage Note:** Any node > 6 cm is classified as **N3**. Presence of **Extranodal Extension (ENE)** significantly upgrades the N-stage in the 8th edition.

Q: Which statement is not true regarding carcinoma of the tongue?

It is commonly an adenocarcinoma.. **Explanation:** **1. Why Option C is the correct answer (The False Statement):** The oral cavity, including the tongue, is lined by stratified squamous epithelium. Therefore, the most common histological type of tongue cancer (accounting for >90% of cases) is **Squamous Cell Carcinoma (SCC)**, not adenocarcinoma. Adenocarcinomas are rare in the tongue and usually arise from minor salivary glands located in the base of the tongue. **2. Analysis of Incorrect Options (True Statements):** * **Option A:** The **lateral border** of the anterior two-thirds of the tongue is indeed the most common site for carcinoma, often due to chronic irritation from sharp teeth or tobacco contact. * **Option B:** The tongue has a very rich lymphatic drainage that crosses the midline. **Cervical lymph node metastasis** is frequent and often occurs early (especially to Level II/Jugulodigastric nodes), which significantly impacts the prognosis. * **Option D:** Chronic irritation from **tobacco chewing**, smoking, and betel nut (paan) are the primary etiological factors for oral malignancies in the Indian subcontinent. **3. High-Yield Clinical Pearls for NEET-PG:** * **Premalignant Lesions:** Erythroplakia (highest risk) and Leukoplakia are significant precursors. * **Staging:** The "T" in TNM staging for the oral cavity is determined by the maximum diameter of the tumor and the **Depth of Invasion (DOI)**. * **Plummer-Vinson Syndrome:** Associated with an increased risk of post-cricoid and tongue base carcinoma. * **Field Cancerization:** This concept explains why patients with one oral primary are at high risk for developing a second primary tumor in the upper aerodigestive tract.

Q: What is a cystic compressible, translucent swelling typically found in the posterior triangle of the neck?

Cystic hygroma. ### Explanation **Cystic Hygroma (Correct Answer)** A cystic hygroma is a congenital malformation of the lymphatic system (lymphangioma) where lymph sacs fail to communicate with the venous system. * **Location:** Most commonly found in the **posterior triangle** of the neck (80% of cases). * **Clinical Features:** It is characteristically **soft, cystic, compressible, and painless**. * **Pathognomonic Sign:** Because it contains clear lymph and has thin walls, it is **brilliantly translucent**. It often exhibits a "cross-fluctuation" sign due to its multilocular nature. **Why the others are incorrect:** * **Branchial Cyst:** Typically located at the junction of the upper 1/3rd and lower 2/3rds of the **anterior border of the sternocleidomastoid muscle**. It is usually opaque (not translucent) and contains cholesterol crystals in the fluid. * **Thyroglossal Cyst:** Found in the **midline** of the neck, usually below the hyoid bone. Its hallmark feature is that it **moves upward on protrusion of the tongue** and deglutition. * **Dermoid Cyst:** Also found in the midline (submental region). It is a "doughy" feeling, opaque swelling that does not transilluminate. **High-Yield Clinical Pearls for NEET-PG:** * **Association:** Cystic hygromas are frequently associated with chromosomal anomalies, most notably **Turner Syndrome** (45, XO) and Down Syndrome. * **Complications:** Sudden increase in size usually indicates **intracystic hemorrhage** or infection. * **Treatment of Choice:** Surgical excision is preferred. For unresectable cases, sclerotherapy (e.g., **OK-432** or Bleomycin) is used. * **Radiology:** On USG/MRI, it appears as a multilocular cystic mass with internal septations.

Q: What is the most common lymph node group involved in tuberculous lymphadenitis?

Posterior cervical. **Explanation:** Tuberculous lymphadenitis (Scrofula) is the most common form of extrapulmonary tuberculosis. In the head and neck region, the **Posterior Cervical** lymph nodes (Level V) are the most frequently involved group. This is a high-yield fact for NEET-PG, as it differs from pyogenic infections which typically involve the anterior chain. * **Why Posterior Cervical is correct:** Unlike pyogenic lymphadenitis which usually spreads from the tonsils or pharynx to the jugulodigastric nodes, TB bacilli often reach the cervical nodes via the lymphatic drainage from the adenoids or through hematogenous spread. Statistically, the posterior triangle nodes are the primary site of involvement in over 50% of cases. * **Why other options are incorrect:** * **Axillary:** While TB can involve axillary nodes, it is far less common than cervical involvement (which accounts for ~70-80% of all peripheral TB lymphadenopathy). * **Intraabdominal:** These nodes (mesenteric) are involved in intestinal TB, but peripheral lymphadenopathy is more common overall. * **Jugulodigastric:** This is the most common node involved in **acute pyogenic tonsillitis** and oral infections, not typically the primary site for TB. **Clinical Pearls for NEET-PG:** * **Presentation:** Characteristically presents as "cold abscesses" (lack of inflammation/heat) and may lead to a **"Collar-stud abscess"** when the infection breaches the deep fascia. * **Diagnosis:** Fine Needle Aspiration Cytology (FNAC) is the initial investigation of choice, showing caseating granulomas. * **Treatment:** Standard Antitubercular Therapy (ATT) for 6 months. Surgery is rarely indicated except for biopsy or drainage of large abscesses.

Q: A 45-year-old man presents with progressive cervical lymph node enlargement for the past 3 months. Which is the most diagnostic investigation?

Lymph node biopsy. **Explanation:** In the evaluation of persistent cervical lymphadenopathy (lasting >3 weeks), the primary goal is to differentiate between reactive, infectious (e.g., Tuberculosis), and neoplastic (e.g., Lymphoma or Metastasis) etiologies. **Why Lymph Node Biopsy is the Correct Answer:** Excisional biopsy is considered the **Gold Standard** and the most diagnostic investigation. Unlike cytology, a biopsy preserves the **node architecture**, which is critical for diagnosing lymphomas (distinguishing Hodgkin’s vs. Non-Hodgkin’s) and performing Immunohistochemistry (IHC). It provides a larger tissue sample, ensuring higher sensitivity and specificity for definitive diagnosis. **Analysis of Incorrect Options:** * **Fine Needle Aspiration Cytology (FNAC):** While FNAC is often the *initial* investigation of choice due to its speed and low cost, it is not the most diagnostic. It only provides cellular detail (cytology) and cannot evaluate the tissue architecture. It has a high false-negative rate in lymphomas. * **X-ray of Soft Tissues:** This is a non-specific imaging modality. While it may show calcifications (suggestive of healed TB) or soft tissue shadows, it cannot provide a pathological diagnosis. * **None of the above:** Incorrect, as biopsy is the definitive diagnostic tool. **NEET-PG High-Yield Pearls:** * **Initial Investigation:** FNAC is usually done first. * **Gold Standard/Definitive Investigation:** Excisional Biopsy. * **Biopsy Technique:** Excisional biopsy (removing the whole node) is preferred over incisional biopsy to prevent sampling errors and tumor seeding. * **Most common cause of chronic cervical lymphadenopathy in India:** Tuberculosis. * **Supraclavicular nodes (Virchow’s node):** Always pathological; usually indicates an underlying malignancy (e.g., Gastric Cancer).

Q: An edentulous 72-year-old man with a 50-year history of cigarette smoking presents with a nontender, hard mass in the lateral neck. What is the simplest way to establish an accurate histological diagnosis of a neck mass suspected to be cancerous?

Fine needle aspiration cytology. ### Explanation **1. Why Fine Needle Aspiration Cytology (FNAC) is Correct:** In an elderly patient with a history of smoking, a hard, nontender lateral neck mass is considered a **metastatic lymph node from an upper aerodigestive tract squamous cell carcinoma (SCC)** until proven otherwise. FNAC is the **gold standard initial investigation** for any neck mass. It is simple, minimally invasive, cost-effective, and has high sensitivity and specificity (often >90%) for diagnosing malignancy. Crucially, it provides a tissue-based diagnosis without the risks of an open biopsy (such as tumor seeding or compromising future neck dissection planes). **2. Why the Other Options are Incorrect:** * **Bone marrow biopsy:** This is used for hematological malignancies (like leukemia or certain stages of lymphoma). While lymphoma can cause neck masses, it is not the primary suspicion in a heavy smoker with a hard, fixed mass. * **Nasopharyngoscopy:** While this is a vital part of the "work-up" to find the **primary tumor** (especially in the occult primary setting), it does not provide a histological diagnosis of the *neck mass* itself. * **CT scan of the head and neck:** This is an imaging modality used for staging and assessing the extent of the disease (involvement of vessels/bones). It provides anatomical detail but cannot provide a histological/cytological diagnosis. **3. Clinical Pearls for NEET-PG:** * **Rule of 80:** In non-thyroid neck masses in adults, 80% are neoplastic; of those, 80% are malignant; of those, 80% are metastatic SCC. * **Avoid Incisional Biopsy:** Never perform an incisional or excisional biopsy of a suspected metastatic neck node before a thorough search for the primary and an FNAC. * **Triple Endoscopy (Panendoscopy):** If FNAC confirms SCC but no primary is seen on physical exam, the next step is panendoscopy (laryngoscopy, esophagoscopy, and bronchoscopy) with directed biopsies.

Question 1

If retromolar pad and tuberosity contact, what should be done?

Accepted Answer

Surgical reduction of tuberosity

Answer

Do not extend dentures to the retromolar area

Answer

Denture fabrication is not possible

Answer

Has no effect on the denture

Question 2

Clicking jaw is due to:

Accepted Answer

Lax temporomandibular joint

Answer

Fracture of the mandible

Answer

Fracture of the maxilla

Answer

Dislocation of the symphysis menti

Question 3

A 2-year-old child presents with a brilliantly translucent swelling in the neck region. What is the most likely diagnosis?

Accepted Answer

Cystic hygroma

Answer

Lipoma

Answer

Teratoma

Answer

Thyroglossal cyst

Question 4

A patient has a 3 cm mass over the lower lip and a single lymph node measuring 3 cm was present on the contralateral side. What is the TNM staging of this lip carcinoma?

Accepted Answer

T2 N2c

Answer

T1 N2a

Answer

T2 N2b

Answer

T1 N2b

Question 5

Which statement is not true regarding carcinoma of the tongue?

Accepted Answer

It is commonly an adenocarcinoma.

Answer

Lateral border is commonly involved.

Answer

Cervical lymph node involvement is frequent.

Answer

Tobacco chewing is a significant risk factor.

Question 6

What is a cystic compressible, translucent swelling typically found in the posterior triangle of the neck?

Accepted Answer

Cystic hygroma

Answer

Branchial cyst

Answer

Thyroglossal cyst

Answer

Dermoid cyst

Question 7

All are true about Cancrum Oris except?

Accepted Answer

Follows chronic infection

Answer

Involves the jaw

Answer

Associated with malnutrition and vitamin deficiency

Answer

Treatment is excision and skin grafting

Question 8

What is the most common lymph node group involved in tuberculous lymphadenitis?

Accepted Answer

Posterior cervical

Answer

Axillary

Answer

Intraabdominal

Answer

Jugulodigastric

Question 9

A 45-year-old man presents with progressive cervical lymph node enlargement for the past 3 months. Which is the most diagnostic investigation?

Accepted Answer

Lymph node biopsy

Answer

X-ray of soft tissues

Answer

Fine Needle Aspiration Cytology (FNAC)

Answer

None of the above

Question 10

An edentulous 72-year-old man with a 50-year history of cigarette smoking presents with a nontender, hard mass in the lateral neck. What is the simplest way to establish an accurate histological diagnosis of a neck mass suspected to be cancerous?

Accepted Answer

Fine needle aspiration cytology

Answer

Bone marrow biopsy

Answer

Nasopharyngoscopy

Answer

CT scan of the head and neck

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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