Head and Neck Surgery Practice Questions

Q: Which of the following is NOT true for carcinoma of the tongue?

Adenocarcinoma is the commonest type. **Explanation:** The correct answer is **B**, as **Squamous Cell Carcinoma (SCC)**—not adenocarcinoma—is the most common histological type of tongue cancer, accounting for over 90% of cases. Adenocarcinomas are rare and typically arise from minor salivary glands within the oral cavity. **Analysis of Options:** * **Option A (Lateral border):** This is the most frequent site for tongue carcinoma (especially the middle third). The dorsum is rarely involved, and the tip/ventral surface are less common. * **Option C (Lymph node involvement):** The tongue has a rich, decussating lymphatic network. Early lymphatic spread to the cervical nodes (specifically Level II/Jugulodigastric) is a hallmark of this disease, often occurring even in early stages. * **Option D (Tobacco chewing):** Chronic irritation from tobacco (chewing or smoking), betel nut, and alcohol are the primary synergistic risk factors for oral SCC. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Oral Cavity Cancer:** Lower lip (globally), but in India, it is the **buccal mucosa** (due to tobacco chewing). * **Premalignant lesions:** Leukoplakia (most common) and Erythroplakia (highest risk of transformation). * **Staging Tip:** Tongue cancers are staged based on size (T) and depth of invasion (DOI). A DOI > 5mm significantly increases the risk of nodal metastasis. * **Management:** Surgery is the primary treatment. For N0 necks, elective neck dissection is often performed if the tumor thickness exceeds 4mm.

Q: A midline swelling is seen in all except:

Branchial cyst. **Explanation:** The key to solving midline neck swelling questions lies in understanding the embryological origins of neck structures. **Why Branchial Cyst is the correct answer:** A **Branchial Cyst** (specifically from the second branchial cleft, which accounts for 95% of cases) is characteristically a **lateral neck swelling**. It is typically located at the junction of the upper third and middle third of the sternocleidomastoid muscle, along its anterior border. Because it arises from the failure of the cervical sinus of His to obliterate, it is anatomically sequestered to the side of the neck and does **not** occur in the midline. **Analysis of Incorrect Options (Midline Swellings):** * **Thyroglossal Cyst:** The most common congenital midline swelling. It develops along the path of the descending thyroid gland (from the foramen caecum to the thyroid isthmus). A classic sign is that it moves upward on protrusion of the tongue. * **Submental Lymphadenopathy:** These nodes are located in the submental triangle, bounded by the anterior bellies of the digastric muscles and the hyoid bone, placing them directly in the midline under the chin. * **Substernal Cyst (Dermoid Cyst):** Often referred to in this context as a submental or suprasternal dermoid cyst, these are sequestration dermoids that occur at lines of embryonic fusion, frequently presenting as painless midline masses. **NEET-PG High-Yield Pearls:** 1. **Movement with Deglutition:** Both Thyroglossal cysts and Thyroid swellings move with swallowing, but **only** Thyroglossal cysts move with tongue protrusion. 2. **Branchial Fistula:** The internal opening is usually in the tonsillar fossa; the external opening is in the lower third of the neck. 3. **Ranula:** A cystic swelling in the floor of the mouth (plunging ranula can present in the neck), usually lateral to the midline.

Q: What is the principal purpose of an acrylic splint in surgical procedures?

To prevent hematoma formation. **Explanation:** The principal purpose of an acrylic splint in surgical procedures, particularly in oral and maxillofacial surgery (such as palatal surgery or skin grafting), is to **prevent hematoma formation**. **1. Why Option A is Correct:** After procedures like the excision of a torus palatinus or palatal flap surgery, a potential space is created between the soft tissue and the underlying bone. Blood can accumulate in this space, leading to a hematoma, which may cause flap necrosis or infection. An acrylic splint acts as a **pressure dressing**, closely adapting the soft tissue flap to the bone. This eliminates dead space and provides continuous compression, which is the most effective way to prevent hematoma formation. **2. Why Other Options are Incorrect:** * **Option B (Dry Socket):** Dry socket (Alveolar Osteitis) is primarily prevented by atraumatic extraction techniques, avoiding smoking, and maintaining the integrity of the initial blood clot. While splints protect surgical sites, they are not the standard treatment or preventive measure for dry socket. * **Option C (Infection):** While preventing a hematoma indirectly reduces the risk of secondary infection (as hematomas act as culture media), the *primary* mechanical function of the splint is compression, not antisepsis or antimicrobial action. **Clinical Pearls for NEET-PG:** * **Dead Space Management:** In surgery, "dead space" is the enemy of healing. Acrylic splints are the intraoral equivalent of a pressure bandage used elsewhere on the body. * **Skin Grafts:** When placing a skin graft in the oral cavity (e.g., vestibuloplasty), an acrylic splint is essential to keep the graft immobilized and in firm contact with the recipient bed. * **Torus Palatinus:** Post-operative splints are mandatory after removing a large palatal torus to prevent the heavy palatal flap from sagging and forming a large clot.

Q: Which incision is used for modified radical neck dissection?

Macfee incision. **Explanation:** The **MacFee incision** is the preferred choice for neck dissections, including Modified Radical Neck Dissection (MRND), particularly when the patient has undergone or will undergo radiotherapy. It consists of **two parallel horizontal incisions**: one in the upper neck (submandibular) and one in the lower neck (supraclavicular). * **Why it is correct:** The primary advantage of the MacFee incision is its superior vascularity. Unlike trifurcate incisions (like the Crile or Schobinger), it avoids a "triple point" junction where skin flaps are prone to necrosis. This makes it the safest option for patients with prior radiation, as it ensures better wound healing and provides excellent cosmetic results. **Analysis of Incorrect Options:** * **A. Kocher Incision:** A subcostal incision used for **Open Cholecystectomy**. (Note: A "Kocher’s collar incision" is used for thyroidectomy, but "Kocher incision" alone refers to the gallbladder approach). * **B. Gridiron Incision:** A muscle-splitting oblique incision in the right iliac fossa used for **Appendectomy** (McBurney’s point). * **D. Sistrunk Incision/Procedure:** This is the definitive surgical management for a **Thyroglossal Cyst**, involving the removal of the cyst, the tract, and the central part of the hyoid bone. **High-Yield Pearls for NEET-PG:** * **Modified Radical Neck Dissection (MRND):** Unlike Radical Neck Dissection (RND), MRND preserves one or more non-lymphatic structures: the Spinal Accessory Nerve (SAN), Internal Jugular Vein (IJV), or Sternocleidomastoid (SCM) muscle. * **Type I MRND:** Preserves SAN. * **Type II MRND:** Preserves SAN and IJV. * **Type III MRND (Functional Neck Dissection):** Preserves all three (SAN, IJV, and SCM). * **Other Neck Incisions:** Hayes Martin and Schobinger are trifurcate incisions used historically but carry a higher risk of flap necrosis at the junction.

Q: Metastasis of carcinoma of the buccal mucosa typically goes to which of the following locations?

Regional lymph nodes. **Explanation:** **1. Why the correct answer is right:** Carcinoma of the buccal mucosa (most commonly **Squamous Cell Carcinoma**) follows a predictable pattern of spread. Like most head and neck epithelial malignancies, it primarily spreads via the **lymphatic system** rather than the bloodstream in its early and intermediate stages. The buccal mucosa has a rich lymphatic network that drains primarily into the **Level I (submandibular and submental)** and **Level II (upper jugular)** cervical lymph nodes. Therefore, regional lymphadenopathy is the most common site of metastasis at the time of presentation. **2. Why the incorrect options are wrong:** * **Head & Brain (Options A & B):** Direct extension to the head (bones/skin) occurs via local invasion, not metastasis. Brain metastasis from oral cavity cancers is extremely rare and usually occurs only in terminal, end-stage disease. * **Lungs (Option D):** While the lungs are the most common site for **distant (hematogenous)** metastasis in head and neck cancers, distant spread occurs much less frequently and much later than regional lymphatic spread. **3. Clinical Pearls for NEET-PG:** * **Most common site of oral cavity cancer in India:** Buccal mucosa (often associated with betel nut/tobacco chewing, known as the "Indian Oral Carcinoma"). * **Staging:** The presence of regional lymph node metastasis is the single most important prognostic factor in oral cavity SCC. * **Drainage Pattern:** Buccal mucosa → Submandibular nodes (Level Ib) → Deep cervical nodes. * **Verrucous Carcinoma (Ackerman’s Tumor):** A variant of buccal cancer that is locally aggressive but characteristically does **not** show lymphatic metastasis.

Q: All of the following nerves are at risk during submandibular gland excision except?

Auriculotemporal nerve. The submandibular gland is located in the submandibular triangle, and its surgical excision requires careful dissection to avoid injuring three major nerves that lie in close proximity. ### **Why Auriculotemporal Nerve is the Correct Answer** The **Auriculotemporal nerve** is a branch of the mandibular nerve (V3) that travels upwards, passing through the parotid gland to provide sensory innervation to the auricle and temple. It also carries postganglionic parasympathetic fibers to the **parotid gland**. Because of its superior and posterior anatomical location, it is at risk during **parotidectomy**, not submandibular gland excision. ### **Analysis of Other Options (Nerves at Risk)** * **Marginal Mandibular Nerve:** This branch of the Facial nerve (CN VII) runs superficial to the submandibular gland, just deep to the platysma. It is the most commonly injured nerve during this surgery, leading to drooping of the corner of the mouth. * **Lingual Nerve:** Located deep to the gland in the floor of the mouth, it loops under the submandibular duct (Wharton’s duct). It is at risk during the ligation of the duct. * **Hypoglossal Nerve (CN XII):** This nerve lies deep to the tendon of the digastric muscle and the submandibular gland. Injury results in ipsilateral tongue deviation. ### **NEET-PG High-Yield Pearls** * **Hayes Martin Maneuver:** To protect the marginal mandibular nerve, the incision is made 2 cm below the lower border of the mandible, and the deep cervical fascia is incised to retract the nerve superiorly within the flap. * **Ganglion Connection:** The submandibular ganglion (parasympathetic) "hangs" from the lingual nerve and must be divided to release the gland. * **Frey’s Syndrome:** This condition involves gustatory sweating due to injury to the **auriculotemporal nerve** during parotid surgery, further distinguishing it from submandibular procedures.

Q: A patient with oral cancer involving the mandible is managed by which of the following treatment modalities?

Resection followed by radiotherapy. **Explanation:** The management of oral cancer depends on the stage and the involvement of adjacent structures. When oral cancer involves the **mandible**, it is classified as T4a disease (locally advanced). **1. Why Option C is Correct:** The standard of care for locally advanced oral squamous cell carcinoma (OSCC) with bone involvement is **upfront surgical resection** (composite resection/commando operation) with adequate margins. Bone involvement is a poor prognostic factor and a high-risk feature. Therefore, surgery is followed by **Adjuvant Radiotherapy (RT)** or Chemoradiotherapy (CRT) to eliminate microscopic residual disease and reduce the risk of local recurrence. **2. Why other options are incorrect:** * **Options A & B:** Chemotherapy or Radiotherapy alone are rarely curative for T4 lesions. Furthermore, radiotherapy is less effective when there is gross bone invasion because the hypoxic environment of the bone limits the efficacy of radiation, and there is a high risk of **osteoradionecrosis** if high doses are used on an involved mandible. * **Option D:** Neoadjuvant radiotherapy (RT before surgery) is generally avoided in the oral cavity as it increases surgical complications, impairs wound healing (especially for flaps), and delays definitive surgical clearance. **Clinical Pearls for NEET-PG:** * **Mandibular Involvement:** If the tumor is close to the bone but not invading the cortex, a **marginal mandibulectomy** is done. If the marrow is involved, a **segmental mandibulectomy** is required. * **Indications for Adjuvant RT:** T3/T4 stage, positive/close margins, perineural invasion (PNI), or lymphovascular invasion (LVI). * **Indications for Adjuvant CRT:** The "Gold Standard" for adding chemotherapy to radiation post-surgery is the presence of **Extracapsular Spread (ECS)** in lymph nodes or **positive surgical margins**.

Question 1

Which of the following is NOT true for carcinoma of the tongue?

Accepted Answer

Adenocarcinoma is the commonest type

Answer

Lateral border is involved

Answer

Cervical lymph node involvement is common

Answer

Tobacco chewing is a significant risk factor

Question 2

A midline swelling is seen in all except:

Accepted Answer

Branchial cyst

Answer

Thyroglossal cyst

Answer

Submental lymphadenopathy

Answer

Substernal cyst

Question 3

Which of the following can cause complications with treatment of mandibular fracture?

Accepted Answer

Compression plate

Answer

Miniplate

Answer

Intermaxillary fixation (IMF)

Answer

Reconstruction plate

Question 4

What is the principal purpose of an acrylic splint in surgical procedures?

Accepted Answer

To prevent hematoma formation

Answer

To prevent dry socket

Answer

To prevent infection

Answer

All of the above

Question 5

What is true about a ranula?

Accepted Answer

A mucocele in the floor of the mouth due to trauma of the submandibular gland duct is called a ranula.

Answer

A ranula is typically painful.

Answer

A ranula does not move along with the movement of the tongue.

Answer

All of the above.

Question 6

Which incision is used for modified radical neck dissection?

Accepted Answer

Macfee incision

Answer

Kocher incision

Answer

Grid iron incision

Answer

Sistrunk incision

Question 7

Metastasis of carcinoma of the buccal mucosa typically goes to which of the following locations?

Accepted Answer

Regional lymph nodes

Answer

Head

Answer

Brain

Answer

Lungs

Question 8

Which among the following is the most common neoplasm of the salivary gland?

Accepted Answer

Pleomorphic adenoma

Answer

Adenoid cystic carcinoma

Answer

Mucoepidermoid carcinoma

Answer

Mixed tumor

Question 9

All of the following nerves are at risk during submandibular gland excision except?

Accepted Answer

Auriculotemporal nerve

Answer

Lingual nerve

Answer

Marginal mandibular nerve

Answer

Hypoglossal nerve

Question 10

A patient with oral cancer involving the mandible is managed by which of the following treatment modalities?

Accepted Answer

Resection followed by radiotherapy

Answer

Chemotherapy alone

Answer

Radiotherapy alone

Answer

Radiotherapy followed by resection

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?