Head and Neck Surgery Practice Questions

Q: Which nerve needs to be carefully identified during parotid gland surgery?

Facial nerve. ***Facial nerve*** - The **facial nerve (cranial nerve VII)** passes directly through the substance of the parotid gland, dividing it into superficial and deep lobes. - Damage to the facial nerve during surgery can result in **facial paralysis**, affecting muscle movement for expression. *Trigeminal nerve* - The **trigeminal nerve (cranial nerve V)** primarily provides sensation to the face and controls muscles of mastication. - It does not course through the parotid gland itself, so direct injury during parotidectomy is less likely. *Greater petrosal nerve* - The **greater petrosal nerve** is a branch of the facial nerve that carries preganglionic parasympathetic fibers to the lacrimal gland. - It originates within the skull and does not traverse the parotid gland, making it an unlikely nerve to be directly injured during parotidectomy. *Chorda tympani* - The **chorda tympani** is another branch of the facial nerve, conveying taste sensation from the anterior two-thirds of the tongue and parasympathetic fibers to the submandibular and sublingual glands. - It does not pass through the parotid gland but is located more medially within the middle ear and infratemporal fossa.

Q: If severe bony undercuts exist, what is the best treatment?

Remove all undercuts so that no undercut exists. ***Remove all undercuts so that no undercut exists*** - **Severe bony undercuts** can prevent the proper seating and insertion of a removable prosthesis, leading to trauma and instability. - **Complete removal** of such undercuts creates a uniform, unobstructed path of insertion, ensuring the prosthesis can be placed and removed without damaging tissues. *Nothing but do only alveolar ridge contouring* - **Alveolar ridge contouring** alone might not be sufficient to address severe bony undercuts, as these often involve areas beyond the immediate ridge crest. - Leaving severe undercuts can still cause ongoing **trauma** to the soft tissues during prosthesis insertion and removal, leading to pain and ulceration. *Remove undercut on one side* - Removing undercuts on only one side while leaving others untreated can lead to a **compromised path of insertion**. - This approach may not fully resolve the problem, potentially still causing difficulty in seating the prosthesis or leading to **uneven stress distribution** upon insertion. *None of the above* - This option is incorrect because removing all severe bony undercuts is indeed a standard and often necessary treatment to ensure successful prosthetic rehabilitation.

Q: A patient with head and neck cancer has a contralateral lymph node of 3 cm size. What is the N staging?

N2c Single or Multiple Bilateral or Contralateral None > 6 cm. ***N2c (Single or Multiple, Bilateral or Contralateral, None > 6 cm)*** - A 3 cm **contralateral** lymph node falls under the **N2c** category according to the AJCC staging system for head and neck cancers. - **N2c** indicates involvement of **contralateral** or **bilateral lymph nodes**, with the largest node being **no greater than 6 cm**. - This is the correct staging for the described clinical scenario. *N2a (Single, Ipsilateral, 3 to 6 cm)* - This option incorrectly describes an **ipsilateral** lymph node, whereas the question specifies a **contralateral** node. - **N2a** is defined by a single **ipsilateral** lymph node between **3 and 6 cm** in greatest dimension. - The key differentiator is **laterality** (ipsilateral vs contralateral). *N1 (Single, Ipsilateral, Equal to or <3 cm)* - This option refers to an **ipsilateral** lymph node that is **3 cm or smaller**, which does not match the contralateral location provided in the question. - **N1** describes a single **ipsilateral** lymph node that is **≤ 3 cm** in greatest dimension. - This fails on both **laterality** (ipsilateral vs contralateral) and **size criteria** (the node is exactly 3 cm, at the boundary). *N3 (Single or Multiple, Ipsilateral/Bilateral/Contralateral, Any node >6 cm)* - While it includes contralateral involvement, **N3** is specifically for a lymph node **greater than 6 cm**, which is not the case for a 3 cm node. - A **N3** classification applies when **any** regional lymph node (ipsilateral, bilateral, or contralateral) exceeds **6 cm** in greatest dimension. - The described 3 cm node does not meet the **size threshold** for N3 staging.

Q: Pell and Gregory classification includes all of the following except:

Root size.. ***Root size*** - The Pell and Gregory classification for impacted mandibular third molars assesses the **spatial relationship** between the impacted tooth and surrounding structures - It specifically evaluates: (1) **Class I-III** based on the relationship to the ramus and second molar, and (2) **Position A-C** based on depth relative to the occlusal plane - **Root size and morphology** are NOT parameters in this classification system, making this the correct answer *Angulation of 3rd molar* - While angulation is important in surgical planning, it is classified by **Winter's classification** (mesioangular, distoangular, vertical, horizontal), not by Pell and Gregory - However, Pell and Gregory does assess the **position** of the tooth, which is different from its angulation *Height of mandible* - The Pell and Gregory classification indirectly relates to mandibular dimensions through its assessment of available **anteroposterior space** - **Class I:** Sufficient space between distal of 2nd molar and anterior border of ramus - **Class II:** Space is less than the mesiodistal width of the 3rd molar crown - **Class III:** 3rd molar is completely within the ramus *Relationship to adjacent teeth* - The Pell and Gregory classification specifically includes the **spatial relationship** of the impacted 3rd molar to the 2nd molar and the ascending ramus - This relationship to adjacent structures is a fundamental component of the classification

Q: Which of the following are stress bearing areas?

Slope of residual ridge, buccal shelf area and hard palate. ***Slope of residual ridge, buccal shelf area and hard palate*** - The **buccal shelf area** in the mandible and the **hard palate** in the maxilla are primary stress-bearing areas due to their dense cortical bone and perpendicular resistance to occlusal forces. - The **slopes of the residual ridge** (particularly the posterior slopes) can also contribute to stress distribution, especially in larger residual ridges. *Buccal shelf area, incisive papilla and palatine rugae* - While the **buccal shelf area** is a primary stress-bearing region, the **incisive papilla** and **palatine rugae** are not. - The **incisive papilla** is a pressure-sensitive area, and the **palatine rugae** are secondary support areas, not designed for primary stress bearing. *Slopes of residual ridge, palatine rugae and midpalatine raphe* - The **slopes of the residual ridge** can contribute to stress bearing, especially in the mandible, but the **palatine rugae** and **midpalatine raphe** are not primary stress-bearing areas. - The **midpalatine raphe** is a non-yielding bony area covered by thin mucosa, making it intolerant to heavy force. *Incisive papilla, slope of the residual ridge and crest of the residual ridge* - The **incisive papilla** is a pressure-sensitive area and the **crest of the residual ridge** is generally a secondary stress-bearing area (or even a relief area if severely atrophied) due to its composition of cancellous bone and thin mucosa. - While the **slope of the residual ridge** can bear some stress, the inclusion of the incisive papilla and the crest as primary bearers makes this option incorrect for the most significant stress-bearing areas.

Q: What type of fracture of petrous temporal bone has the highest chance of facial nerve paralysis?

Transverse. ***Transverse*** - **Transverse fractures** of the petrous temporal bone run perpendicular to the long axis of the petrous bone and are typically caused by direct blows to the occiput or high-energy trauma. - These fractures have the **highest incidence (30-50%)** of facial nerve paralysis due to direct involvement of the facial nerve within the petrous canal, often resulting in complete and immediate paralysis from transection or severe crush injury. *All have equal incidence* - This is incorrect because the incidence of facial nerve paralysis varies significantly depending on the **type and direction of the fracture** pattern. - Different fracture orientations impact the facial nerve's intricate intratemporal course in distinct ways, resulting in markedly different injury rates. *Oblique* - **Oblique fractures** are less common and their impact on the facial nerve is variable, generally considered intermediate between longitudinal and transverse fractures. - The specific angulation and degree of facial canal involvement determine the risk, but the incidence is typically lower than transverse fractures. *Longitudinal* - **Longitudinal fractures** run parallel to the long axis of the petrous bone, typically resulting from lateral temporal impacts. - These fractures have a **much lower incidence (10-20%)** of facial nerve paralysis, usually incomplete and often due to edema or hematoma rather than direct nerve transection, as they tend to spare the facial nerve's intratemporal course.

Q: Which of the following statements about parotid tumors are correct? a) Pleomorphic adenoma is the most common variety b) Malignant disease is the most common variety c) Facial nerve involvement indicates malignancy d) Superficial parotidectomy is the treatment of choice

Only statements a, c, and d are correct. ***Only statements a, c, and d are correct*** - **Pleomorphic adenoma** is indeed the most common parotid tumor (60-70% of all parotid tumors) - **Facial nerve involvement** is a strong clinical indicator of malignancy, as benign tumors typically displace rather than invade the nerve - **Superficial parotidectomy** with facial nerve preservation is the standard surgical treatment for most parotid tumors - Statement b is false: approximately **80% of parotid tumors are benign**, with malignant tumors representing only ~20% *Only statements a and c are correct* - While this correctly identifies that pleomorphic adenoma is most common and facial nerve involvement suggests malignancy, it incorrectly excludes statement d - Superficial parotidectomy is indeed the standard treatment for most parotid tumors *All statements are correct* - This is incorrect because statement b is false - Malignant disease is NOT the most common variety; benign tumors (especially pleomorphic adenomas) predominate *Only statements b and d are correct* - This is incorrect because statement b is false - Malignant disease represents only ~20% of parotid tumors, not the most common variety

Q: 65 year old man with carcinoma of tongue of > 4 cm size and multiple lymph nodes of > 6 cm noted. What is the AJCC staging?

T3 N3 M0. ***T3 N3 M0*** - The primary tumor (T) is classified as **T3** because its greatest dimension is greater than 4 cm (or any tumor with depth of invasion > 10 mm). - The nodal involvement (N) is classified as **N3** (specifically **N3a**) because any lymph node greater than 6 cm, regardless of number, qualifies as N3a per **AJCC 8th Edition** staging. - This is the correct staging based on the clinical findings provided. *T2 N3 M0* - This is incorrect because a tumor > 4 cm automatically classifies as **T3**, not T2. - **T2** is reserved for tumors > 2 cm but ≤ 4 cm with depth of invasion ≤ 10 mm, or tumors ≤ 2 cm with depth of invasion > 5 mm and ≤ 10 mm. - While the N3 classification is correct, the T staging is wrong. *T3 N2 M0* - This is incorrect because although **T3** is correct for a tumor > 4 cm, the nodal classification is wrong. - Any lymph node > 6 cm is classified as **N3a**, not N2. - **N2** classifications require all involved nodes to be ≤ 6 cm in size. *T2 N2 M0* - This is incorrect as both the T and N classifications are inaccurate. - A tumor > 4 cm is **T3**, not T2. - Lymph node(s) > 6 cm are **N3a**, not N2. - This represents understaging of both the primary tumor and nodal disease.

Q: A tumor in the cheek measuring 3 cm in size with contralateral mobile lymph nodes comes under:

T2N2M0. ***T2N2M0*** - A 3 cm tumor in the cheek is classified as **T2** for head and neck cancers, which designates a tumor greater than 2 cm but not exceeding 4 cm. - **Contralateral mobile lymph nodes** are classified as **N2c** if bilateral or contralateral nodes are involved and are ≤6 cm and mobile, which falls under the broader N2 classification. *T3N3M0* - **T3** generally refers to a tumor greater than 4 cm or with specific features like bone invasion in some sites, neither of which is present here. - **N3** indicates a lymph node greater than 6 cm in greatest dimension, or involving supraclavicular nodes, which is not described. *T3N2M0* - As explained, a 3 cm tumor is a **T2**, not a T3. - **N2** applies to the contralateral mobile lymph nodes, but the tumor size is incorrect for a T3 classification. *T4N2M0* - **T4** indicates a very large tumor (often >4 cm) or one with extensive invasion into adjacent structures, which is not the case for a 3 cm cheek tumor. - While **N2** may apply to the nodes, the T classification is incorrect.

Q: When bleeding doesn't stop on applying pressure and the patient has intermittent pain too, what should be the treatment taken into consideration?

Pulpectomy. ***Pulpectomy*** - **Uncontrolled bleeding** after applying pressure and **intermittent pain** are signs of **irreversible pulpitis** or pulp necrosis extending into the root canals. - A **pulpectomy** is indicated to remove the entire coronal and radicular pulp tissue to alleviate symptoms and prevent further infection. *Pulpotomy* - A **pulpotomy** is performed when active bleeding from the radicular pulp tissue can be controlled, indicating **reversible pulpitis** localized to the coronal pulp. - The goal is to preserve the vitality of the **radicular pulp**. *DPC* - **Direct pulp capping (DPC)** is indicated for small, mechanical pulp exposures in a tooth with a **healthy pulp** and no spontaneous pain. - It aims to preserve pulp vitality by placing a protective material directly over the exposed pulp. *None of the options* - Given the specific symptoms of **uncontrolled bleeding** and **intermittent pain**, a **pulpectomy** is a clearly indicated treatment option. - Therefore, it is incorrect to state that none of the options are applicable.

Question 1

Which nerve needs to be carefully identified during parotid gland surgery?

Accepted Answer

Facial nerve

Answer

Trigeminal nerve

Answer

Greater petrosal nerve

Answer

Chorda tympani

Question 2

If severe bony undercuts exist, what is the best treatment?

Accepted Answer

Remove all undercuts so that no undercut exists

Answer

Nothing but do only alveolar ridge contouring

Answer

Remove undercut on one side

Answer

None of the above

Question 3

A patient with head and neck cancer has a contralateral lymph node of 3 cm size. What is the N staging?

Accepted Answer

N2c
Single or Multiple
Bilateral or Contralateral
None > 6 cm

Answer

N2a
Single
Ipsilateral
3 to 6 cm

Answer

N1
Single
Ipsilateral
Equal to or <3 cm

Answer

N3
Single or Multiple
Ipsilateral, Bilateral or Contralateral
Any node >6 cm

Question 4

Pell and Gregory classification includes all of the following except:

Accepted Answer

Root size.

Answer

Angulation of 3rd molar.

Answer

Height of mandible.

Answer

Relationship to adjacent teeth.

Question 5

Which of the following are stress bearing areas?

Accepted Answer

Slope of residual ridge, buccal shelf area and hard palate

Answer

Buccal shelf area, incisive papilla and palatine rugae

Answer

Slopes of residual ridge, palatine rugae and midpalatine raphe

Answer

Incisive papilla, slope of the residual ridge and crest of the residual ridge

Question 6

What type of fracture of petrous temporal bone has the highest chance of facial nerve paralysis?

Accepted Answer

Transverse

Answer

All have equal incidence

Answer

Oblique

Answer

Longitudinal

Question 7

Which of the following statements about parotid tumors are correct?
a) Pleomorphic adenoma is the most common variety
b) Malignant disease is the most common variety
c) Facial nerve involvement indicates malignancy
d) Superficial parotidectomy is the treatment of choice

Accepted Answer

Only statements a, c, and d are correct

Answer

Only statements a and c are correct

Answer

All statements are correct

Answer

Only statements b and d are correct

Question 8

65 year old man with carcinoma of tongue of > 4 cm size and multiple lymph nodes of > 6 cm noted. What is the AJCC staging?

Accepted Answer

T3 N3 M0

Answer

T2 N3 M0

Answer

T3 N2 M0

Answer

T2 N2 M0

Question 9

A tumor in the cheek measuring 3 cm in size with contralateral mobile lymph nodes comes under:

Accepted Answer

T2N2M0

Answer

T3N3M0

Answer

T3N2M0

Answer

T4N2M0

Question 10

When bleeding doesn't stop on applying pressure and the patient has intermittent pain too, what should be the treatment taken into consideration?

Accepted Answer

Pulpectomy

Answer

Pulpotomy

Answer

DPC

Answer

None of the options

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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