Head and Neck Surgery Practice Questions

Q: The commonest site for thyroglossal cyst is :

Subhyoid. ***Subhyoid (Infrahyoid)*** - The **subhyoid (infrahyoid) region** is the most common location for thyroglossal cysts, accounting for **50-65% of cases**. - The thyroglossal duct passes through or is intimately related to the **body of the hyoid bone** during embryonic descent of the thyroid gland from the foramen cecum [1], [2]. - Cysts most frequently form **at or just below the level of the hyoid bone** in the midline neck. - These cysts characteristically **move upward with swallowing and tongue protrusion** due to their attachment to the hyoid bone. *Suprahyoid* - Suprahyoid cysts occur **above the hyoid bone** and account for approximately **20-25% of cases**. - While common, they are **less frequent than subhyoid cysts**. - These may present higher in the neck but still maintain the characteristic midline location. *Submentum* - The submental region is **anterior and superior to the hyoid bone** in the midline. - Thyroglossal cysts in this location are **uncommon** as the duct's path runs more posteriorly in relation to this space. - True submental cysts are rare and must be differentiated from dermoid cysts. *Foramen caecum* - This is the **embryological origin** of the thyroglossal duct at the base of the tongue [1], [2]. - Cysts at this location are called **lingual thyroglossal cysts** and are very rare (1-2% of cases) [1]. - They present as tongue base masses and can cause dysphagia or airway obstruction.

Q: The structures removed in radical neck dissection include: 1. Sternocleidomastoid muscle 2. Submandibular gland 3. Internal jugular vein 4. Accessory nerve

1, 2, 3 and 4. ***1, 2, 3 and 4*** - A **radical neck dissection** involves the removal of the **sternocleidomastoid muscle**, **internal jugular vein**, and **spinal accessory nerve (cranial nerve XI)**, along with all cervical lymph node groups from levels I to V, and the submandibular gland. - This extensive procedure is designed to achieve complete tumor clearance, particularly in cases of advanced head and neck cancers with suspected or confirmed nodal metastases. *1 and 2 only* - This option is incomplete as a radical neck dissection targets more structures than just the **sternocleidomastoid muscle** and **submandibular gland**. - While these two structures are removed, the procedure also extensively addresses major neurovascular structures and lymph nodes to ensure comprehensive cancer eradication. *1 and 3 only* - This option is incomplete because a radical neck dissection also involves the removal of the **submandibular gland** and the **accessory nerve**, in addition to the sternocleidomastoid muscle and internal jugular vein. - The goal is to clear all potential pathways of cancer spread in the neck. *2 and 4 only* - This option is incorrect as it omits other key structures removed in a radical neck dissection, such as the **sternocleidomastoid muscle** and the **internal jugular vein**. - These structures are critical components of the surgical field to adequately remove all affected tissues.

Q: Consider the following statements : Branchial cysts : 1. are associated with tracks passing between the carotid bifurcation. 2. usually present in early adulthood. 3. occur along the lower one-third of the anterior border of the sternocleidomastoid muscle. 4. develop from the vestigial remnants of the fourth branchial cleft. Which of the statements given above are correct?

1, 2 and 3 only. ***1, 2 and 3 only*** - **Branchial cysts** (specifically **second branchial cleft cysts**) are frequently associated with a **sinus tract** that passes between the **internal and external carotid arteries** (carotid bifurcation) and opens into the tonsillar fossa. - They commonly present in **late childhood or early adulthood** as a slowly enlarging, painless mass, often located along the **anterior border of the sternocleidomastoid muscle**, typically at the junction of the upper two-thirds and lower one-third of the neck. *2, 3 and 4 only* - This option incorrectly states that branchial cysts develop from the **fourth branchial cleft**. Most common branchial cysts are derived from the **second branchial cleft** (accounting for >90% of cases). - While statements 2 and 3 are correct regarding presentation and location, the origin from the fourth branchial cleft is generally not applicable to the most prevalent type of branchial cyst. *1, 2, 3 and 4* - This option includes the incorrect statement that branchial cysts typically originate from the **fourth branchial cleft**. The vast majority (over 90-95%) of branchial cleft anomalies arise from the **second branchial cleft**. - While all other statements (1, 2, and 3) are characteristic of second branchial cleft cysts, the inclusion of the fourth branchial cleft origin makes this option incorrect. *1 and 2 only* - This option correctly identifies the association with tracks passing through the carotid bifurcation and presentation in early adulthood. - However, it omits the correct statement that branchial cysts typically occur along the **lower one-third of the anterior border of the sternocleidomastoid muscle**, which is a key anatomical location and an important clinical finding for diagnosis.

Q: With reference to Le Fort I fracture, consider the following statements : 1. Fracture line separates alveolus and palate from the facial skeleton. 2. Fracture line passes from the pyriform aperture. 3. Fracture line runs posteriorly to include pterygoid plates. 4. Fracture line passes through orbit. Which of the statements given above are correct?

1, 2 and 3. ***Correct Answer: 1, 2 and 3*** - A **Le Fort I fracture** (floating palate fracture) involves a horizontal fracture line separating the **maxillary alveolus and hard palate** from the rest of the facial skeleton, confirming statement 1. - The fracture path includes the **pyriform aperture** anteriorly (statement 2) and extends posteriorly to involve the **pterygoid plates of the sphenoid bone** (statement 3). - Statement 4 is **incorrect** because Le Fort I fractures do **not** involve the orbit; this is a low-level fracture below the orbital floor. *Incorrect: 1 and 2 only* - This option is incomplete as it omits statement 3, which is a defining characteristic of Le Fort I fractures. - The fracture **must** extend posteriorly to include the **pterygoid plates** to be classified as a Le Fort I. *Incorrect: 2, 3 and 4* - Statement 4 is incorrect for a Le Fort I fracture. - Le Fort I fractures are located **inferiorly** and do **not** involve the orbital floor or walls. - Orbital involvement is characteristic of **Le Fort II** (pyramidal fracture) or **Le Fort III** (craniofacial dysjunction) fractures. *Incorrect: 1 and 3 only* - This option omits statement 2, which accurately describes the involvement of the **pyriform aperture** in Le Fort I fractures. - The fracture line **consistently** passes through the pyriform aperture anteriorly as it traverses the lower maxilla.

Q: In a lateral facial wound, if facial nerve injury is suspected, it should be:

Primary repair should be attempted. ***Primary repair should be attempted*** - **Early surgical repair** of facial nerve injuries, ideally within the first 72 hours, offers the best chance for **functional recovery**. - **Primary repair** involves direct reapproximation and meticulous suturing of the severed nerve ends under magnification. *Left alone* - Leaving a suspected facial nerve injury untreated can lead to **permanent facial paralysis** and significant functional and aesthetic deficits. - The facial nerve has a limited capacity for spontaneous regeneration, especially after a **complete transection**. *Secondary repair using microscope gives best result* - While microscopic techniques are crucial for nerve repair, **secondary repair** (performed weeks or months after the injury) generally yields poorer outcomes compared to primary repair. - **Scar tissue formation** and **nerve end retraction** make secondary repair more challenging and less effective. *Skin and subcutaneous flaps to be raised to cover the cut ends* - This approach addresses wound closure but **does not repair the underlying nerve injury**, leading to persistent motor deficits. - Covering the nerve ends without repair would still result in **facial paralysis** as the nerve fibers cannot reconnect across the gap.

Q: A 70 year old male having comorbidities presents with benign appearing parotid tumour. The best option is:

Superficial Parotidectomy. ***Superficial Parotidectomy*** - This is the **standard surgical treatment** for benign parotid tumors, even in elderly patients with comorbidities, as it offers the best balance of **low recurrence risk** and **preservation of facial nerve function**. - The procedure removes the superficial lobe of the parotid gland, where most benign tumors are located, and allows for **intraoperative facial nerve monitoring**. *Tumour enucleation* - This procedure has a **higher risk of tumor recurrence** as it does not remove a cuff of healthy tissue around the tumor. - It also has a greater chance of **facial nerve injury** due to the lack of clear dissection planes. *Radio therapy* - Radiotherapy is generally reserved for **malignant parotid tumors** or as an adjuvant therapy after incomplete resection of high-grade malignancies. - It carries risks of **xerostomia**, radiation-induced fibrosis, and potential secondary malignancies, making it less suitable for benign conditions. *Aspiration biopsy confirmation* - While an aspiration biopsy (Fine Needle Aspiration Cytology, FNAC) is crucial for **preoperative diagnosis**, it is not a treatment option. - It helps in planning the definitive surgical approach but does not address the tumor itself.

Q: A gentleman of 60 years presented with a brawny swelling of the submandibular region with inflammatory edema of mouth and putrid halitosis. Most likely he is suffering from

Ludwig's angina. ***Ludwig's angina*** - This is a **rapidly progressive cellulitis** of the submandibular, sublingual, and submental spaces, commonly originating from **odontogenic infections**. - The classic presentation includes **brawny edema** (firm, woody induration) of the submandibular region, inflammatory edema of the mouth, and **putrid halitosis** indicative of an anaerobic infection. *Acute lymphadenitis* - This involves inflammation of the lymph nodes, typically characterized by **tender, enlarged nodes**. - While it can be associated with infection, it usually does not present with the diffuse, *brawny* swelling of the floor of the mouth and submandibular area as described, nor the severe systemic symptoms often linked to Ludwig's angina. *Tubercular adenitis* - This is a **chronic granulomatous inflammation** of lymph nodes, typically presenting as slowly enlarging, **non-tender masses**. - It does not cause acute, rapidly spreading cellulitis or *brawny* edema with severe halitosis, which are hallmark features of Ludwig's angina. *Chronic lymphadenitis* - This refers to persistent or recurrent inflammation of lymph nodes, often due to protracted infection or inflammatory processes. - It usually manifests as **enlarged, firm, sometimes mobile lymph nodes**, but does not involve the acute, diffuse, and rapidly spreading *brawny* edema characteristic of a severe fascial space infection like Ludwig's angina.

Q: Tongue fixation in a patient with carcinoma tongue is staged as

T4. ***T4*** - **Tongue fixation** in carcinoma of the tongue indicates advanced local disease classified as **T4a stage** according to AJCC TNM staging. - This finding suggests invasion of **extrinsic tongue muscles**, which causes loss of tongue mobility and represents moderately advanced local disease. - T4a tumors invade through cortical bone, involve the inferior alveolar nerve, floor of mouth, or skin of face, or in the case of tongue, involve deep extrinsic muscles causing fixation. *T1* - **T1 tumors** are small lesions measuring **≤2 cm** in greatest dimension with **depth of invasion (DOI) ≤5 mm**. - They are superficial without invasion of deep structures or causing any functional impairment like tongue fixation. *T2* - **T2 tumors** measure **≤2 cm with DOI >5 mm and ≤10 mm**, OR **>2 cm but ≤4 cm with DOI ≤10 mm**. - While larger than T1, they do not involve deep extrinsic muscles or cause tongue fixation. *T3* - **T3 tumors** are defined as tumors **>4 cm** OR **any tumor with DOI >10 mm**. - Although T3 indicates larger tumor size and deeper invasion, **tongue fixation** specifically indicates T4a stage due to involvement of extrinsic tongue musculature.

Q: Which one of the following structures is not removed during a classical radical neck dissection?

Trapezius. ***Trapezius*** - The **trapezius muscle** is consistently spared (not removed) in a classical radical neck dissection, although it becomes non-functional due to sacrifice of its motor nerve supply. - While the muscle remains anatomically in place, removal of the **accessory nerve** leads to denervation of the trapezius, causing severe shoulder dysfunction including **shoulder drop** and inability to abduct the arm past 90 degrees. *Accessory nerve* - The **accessory nerve (cranial nerve XI)** is sacrificed in a classical radical neck dissection to ensure complete removal of lymphatic tissue and metastatic disease. - Its removal results in **denervation and paralysis of the trapezius muscle**, leading to shoulder weakness, shoulder drop, and limited shoulder abduction. - The accessory nerve also innervates the sternocleidomastoid, though this muscle is removed in the procedure. *Sternocleidomastoid* - The **sternocleidomastoid muscle** is removed in a classical radical neck dissection for oncological clearance, as lymph nodes closely associated with it can harbor metastatic disease. - Its removal contributes to cosmetic defect and can affect neck contour and mobility. *Internal jugular vein* - The **internal jugular vein** is resected during a classical radical neck dissection to achieve en bloc removal of lymphatic tissue in levels II, III, and IV, which often contain metastatic disease. - Its removal can lead to **venous congestion** in the head and neck initially, although collateral circulation through the external jugular and vertebral venous systems usually develops over time.

Question 1

The commonest site for thyroglossal cyst is :

Accepted Answer

Subhyoid

Answer

Submentum

Answer

Suprahyoid

Answer

Foramen caecum

Question 2

The structures removed in radical neck dissection include:

1. Sternocleidomastoid muscle
2. Submandibular gland
3. Internal jugular vein
4. Accessory nerve

Accepted Answer

1, 2, 3 and 4

Answer

1 and 2 only

Answer

1 and 3 only

Answer

2 and 4 only

Question 3

Consider the following statements :

Branchial cysts :

1. are associated with tracks passing between the carotid bifurcation.
2. usually present in early adulthood.
3. occur along the lower one-third of the anterior border of the sternocleidomastoid muscle.
4. develop from the vestigial remnants of the fourth branchial cleft.

Which of the statements given above are correct?

Accepted Answer

1, 2 and 3 only

Answer

2, 3 and 4 only

Answer

1, 2, 3 and 4

Answer

1 and 2 only

Question 4

With reference to Le Fort I fracture, consider the following statements :

1. Fracture line separates alveolus and palate from the facial skeleton.

2. Fracture line passes from the pyriform aperture.

3. Fracture line runs posteriorly to include pterygoid plates.

4. Fracture line passes through orbit.
Which of the statements given above are correct?

Accepted Answer

1, 2 and 3

Answer

1 and 2 only

Answer

2, 3 and 4

Answer

1 and 3 only

Question 5

A 50 year old man with long history of swelling in his right parotid region had sudden history of occasional pain, nerve weakness along with paresthesia. His fine needle aspiration cytology was inconclusive. What should be the next step?

Accepted Answer

MRI

Answer

CT Scan

Answer

Trucut Biopsy

Answer

Superficial Parotidectomy

Question 6

In a lateral facial wound, if facial nerve injury is suspected, it should be:

Accepted Answer

Primary repair should be attempted

Answer

Left alone

Answer

Secondary repair using microscope gives best result

Answer

Skin and subcutaneous flaps to be raised to cover the cut ends

Question 7

A 70 year old male having comorbidities presents with benign appearing parotid tumour. The best option is:

Accepted Answer

Superficial Parotidectomy

Answer

Tumour enucleation

Answer

Radio therapy

Answer

Aspiration biopsy confirmation

Question 8

A gentleman of 60 years presented with a brawny swelling of the submandibular region with inflammatory edema of mouth and putrid halitosis. Most likely he is suffering from

Accepted Answer

Ludwig's angina

Answer

Acute lymphadenitis

Answer

Tubercular adenitis

Answer

Chronic lymphadenitis

Question 9

Tongue fixation in a patient with carcinoma tongue is staged as

Accepted Answer

T4

Answer

T1

Answer

T2

Answer

T3

Question 10

Which one of the following structures is not removed during a classical radical neck dissection?

Accepted Answer

Trapezius

Answer

Accessory nerve

Answer

Sternocleidomastoid

Answer

Internal jugular vein

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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