Head and Neck Surgery Practice Questions

Q: A 60-year-old man presents with painless, progressive enlargement of the parotid gland. What is the most likely diagnosis?

Parotid gland tumor. ***Parotid gland tumor*** - A **painless, progressive enlargement** of the parotid gland, especially in an older individual, is highly suspicious for a **parotid gland tumor**. - Tumors of the parotid gland can be benign (e.g., pleomorphic adenoma) or malignant (e.g., mucoepidermoid carcinoma), but the key presentation is a **gradual, asymptomatic increase in size**. *Parotitis* - **Parotitis** typically presents with **acute pain, tenderness, and swelling** of the parotid gland, often accompanied by fever and malaise. - It is an inflammatory condition, usually bacterial or viral, and not characterized by a painless, progressive enlargement. *Sialolithiasis* - **Sialolithiasis** (salivary gland stones) usually causes intermittent, **painful swelling of the gland, especially during meals**, due to obstruction of saliva flow. - The pain and swelling are typically episodic and related to eating, which is not described in this case. *Mumps* - **Mumps** is a viral infection that causes **acute, painful swelling of the parotid glands**, usually bilateral, along with fever, headache, and fatigue. - It is more common in children and vaccinated adults can still get mild forms, but the presentation is acute and inflammatory, not painless and progressive.

Q: A patient with a pituitary tumor undergoes transsphenoidal surgery for tumor resection. Which anatomical structure serves as the surgical access route in this procedure?

Sphenoid sinus. ***Sphenoid sinus*** - The **transsphenoidal approach** uses the sphenoid sinus as the **key surgical corridor** to access the pituitary gland located in the sella turcica. - This method is preferred for pituitary tumors due to its **minimal invasiveness** and reduced risk of damage to surrounding brain structures. - The sphenoid sinus provides **direct posterior access** to the sellar floor, making it the critical anatomical landmark for this procedure. *Nasal septum* - The **nasal septum** is incised or displaced during the initial stages to reach the sphenoid sinus. - While it is traversed during the approach, it serves as an **entry pathway** rather than the definitive surgical corridor to the pituitary gland. - The septum is part of the route but not the structure that provides direct access to the sella turcica. *Maxillary sinus* - The **maxillary sinus** is located in the maxilla and is not in the direct line of access to the pituitary gland via a transsphenoidal approach. - It is typically approached for conditions like sinusitis or tumors originating within the sinus itself, not for pituitary lesions. *Ethmoid sinus* - The **ethmoid sinus** lies anterior and superior to the sphenoid sinus, forming part of the orbit and the roof of the nasal cavity. - While it can be traversed in some extended endoscopic skull base approaches, it is not the primary or most direct route to the pituitary gland for standard transsphenoidal surgery.

Q: A middle-aged man with a swelling over the neck since childhood with the overlying skin not intact which had a bag or worm-like appearance with a black spot in the middle. What will be the diagnosis?

Plexiform neurofibroma. ***Plexiform neurofibroma*** - The description of a "bag or worm-like appearance" (akin to a **bag of worms**) and a "black spot in the middle" (representing a dermal defect or associated nevus/hyperpigmentation) is classic for a **plexiform neurofibroma**. - This type of neurofibroma, often present since **childhood**, involves plexiform arrangements of nerves and can result in significant tissue distortion and overlying skin changes, characteristic of **Neurofibromatosis Type 1 (NF1)**. - The non-intact overlying skin with the pathognomonic appearance makes this diagnosis highly specific. *Carotid body tumor* - A carotid body tumor (paraganglioma) presents as a **pulsatile lateral neck mass** that moves side-to-side but not up-and-down (Fontaine sign). - It would not have a "bag of worms" texture or the characteristic skin changes with a black spot described in this case. - These are typically firm masses occurring in adults, not childhood-onset swellings. *Sebaceous cyst* - A sebaceous cyst is a **smooth, often freely mobile** subcutaneous lump with a central punctum, not typically presenting with a "bag of worms" texture. - It results from a blocked sebaceous gland and usually has a discrete, contained appearance without the plexiform pattern. - While present since childhood sometimes, it lacks the specific features described here. *Cystic hygroma* - A cystic hygroma (lymphangioma) presents as a **soft, brilliantly transilluminant mass** typically in the posterior triangle of the neck. - It is usually diagnosed in infancy or early childhood and is compressible but smooth, not having a "bag of worms" appearance. - It does not typically have associated skin changes like a black spot or the characteristic texture of plexiform neurofibroma.

Q: What is the most likely diagnosis for the parotid mass with mixed consistency shown in the image?

Pleomorphic adenoma. ***Pleomorphic adenoma*** - The **mixed consistency** of the parotid mass indicates a **benign tumor**, predominantly of epithelial and mesenchymal origin, typical of pleomorphic adenomas. - This type of tumor is usually **pain-free** and can exhibit a **soft** and **firm** texture on examination [1]. *Sebaceous cyst* - Typically presents as a **smooth, fluctuant nodule** and usually has a **firm consistency** rather than mixed. - Generally not seen as a parotid mass; usually found on the skin in areas with sebaceous glands. *Dermoid cyst* - Generally presents as a **well-defined, soft, and mobile mass**, not commonly associated with mixed consistency. - Often contains **keratin** and has a more homogenous consistency rather than the mixed characteristics of pleomorphic adenoma. *All* - As not all options are suitable for the description of a **mixed consistency parotid mass**, this option is incorrect. - Only **pleomorphic adenoma** aligns with the specific clinical presentation detailed in the question [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 751-753.

Q: For lower lip carcinoma of <1 cm in size, the treatment of choice will be:

Excision. ***Excision*** - For **small lesions (<1 cm)** of lower lip carcinoma, **surgical excision** with adequate margins is the standard and most effective treatment. - This approach offers excellent **local control** and allows for **histopathological evaluation** of the tumor and margins. *Radiation* - While radiation therapy can be effective for lip carcinoma, it is generally reserved for **larger tumors**, those with positive margins after excision, or patients who are **poor surgical candidates**. - For small lesions, surgical excision typically provides a better cosmetic and functional outcome with a single treatment. *Chemotherapy* - **Chemotherapy** is rarely used as a primary treatment for early-stage lower lip carcinoma; its role is usually limited to **advanced or metastatic disease**. - It does not offer the same local control as surgery or radiation for small, localized lesions. *Radiation and chemotherapy* - **Combined modality therapy** with radiation and chemotherapy is typically reserved for **locally advanced disease**, tumors with high-risk features, or patients with **nodal involvement**. - For a small lesion (<1 cm), this approach would be **overtreatment** and expose the patient to unnecessary side effects.

Q: Which surgical landmarks are used for locating the facial nerve?

All of the options. ***All of the options*** - The **tympano-mastoid suture**, the **tragal pointer**, and the **posterior belly of the digastric** muscle are all commonly used surgical landmarks for identifying and preserving the facial nerve during parotidectomy or other procedures in the vicinity. - Using multiple landmarks provides a more reliable and precise localization of the facial nerve, reducing the risk of iatrogenic injury. *Tympano - mastoid suture* - This suture line is an important external landmark that helps guide the dissection towards the **stylomastoid foramen**, where the facial nerve exits the skull. - The facial nerve typically lies deep and anterior to this suture, providing a valuable starting point for identification. *Tragal pointer* - The **tragal pointer** (cartilaginous projection of the tragus) points directly towards the main trunk of the facial nerve as it enters the parotid gland. - It is a highly reliable superficial landmark, particularly useful in locating the superior aspect of the facial nerve trunk. *Posterior belly of digastric* - The **posterior belly of the digastric muscle** serves as a deep landmark, as the facial nerve typically courses immediately superior and lateral to it. - Dissection along the superior border of this muscle can lead directly to the facial nerve trunk, especially when dissecting inferiorly.

Q: A 23-year-old male patient presents with midline swelling in the neck. The swelling moves with deglutition and protrusion of the tongue. What is the likely diagnosis?

Thyroglossal cyst. ***Thyroglossal cyst*** - A **thyroglossal cyst** is a congenital anomaly that arises from the persistent **thyroglossal duct**, a remnant of the thyroid's embryologic descent. - Its classic diagnostic feature is its movement with **deglutition** (due to attachment to the hyoid bone, which moves during swallowing) and **protrusion of the tongue** (as the thyroglossal duct is connected to the base of the tongue). *Brachial cyst* - A **brachial cyst** is a congenital neck mass that typically presents as a lateral neck swelling, often located along the anterior border of the **sternocleidomastoid muscle**. - Unlike a thyroglossal cyst, it does not typically move with **deglutition** or **tongue protrusion**. *Plunging ranula* - A **plunging ranula** is a type of mucocele that arises from the **sublingual gland** and extends below the mylohyoid muscle into the neck. - It presents as a cervical mass but is typically located in the floor of the mouth or submandibular region and does not move with **deglutition** or **tongue protrusion**. *Dermoid cyst* - A **dermoid cyst** is a congenital cyst that can occur anywhere on the body, including the head and neck, often presenting as a painless mass. - It arises from sequestered embryonic ectoderm and mesoderm, containing skin appendages, but it does not move with **deglutition** or **tongue protrusion**.

Q: A middle-aged man presents with a swelling in the neck that has been present since childhood. The swelling has a bag or worm-like appearance and features a central black spot. Based on this description, what is the most likely diagnosis?

Plexiform neurofibroma. ***Plexiform neurofibroma*** - The description of a swelling since childhood with a **bag-of-worms appearance** and a **central black spot** is highly characteristic of a plexiform neurofibroma, a benign tumor of peripheral nerves. - These lesions are often associated with **neurofibromatosis type 1 (NF1)** and can grow quite large, causing cosmetic and functional concerns. - The **central black spot** represents pigmentation often seen in neurofibromas, particularly in NF1. *Cirsoid aneurysm* - A cirsoid aneurysm is a **congenital arteriovenous malformation** characterized by a tortuous mass of dilated blood vessels. - While it can manifest as a swelling, it typically presents with a **palpable thrill and audible bruit**, and its appearance is not usually described as having a central black spot. *Varicocele* - A varicocele is an **abnormal enlargement of the pampiniform plexus veins** in the scrotum, often described as a **bag of worms**, but it occurs exclusively in the scrotum. - It would not be found in the neck and does not feature a central black spot. *Lymphangioma* - A lymphangioma is a **benign malformation of the lymphatic system** that can present as a soft, compressible mass, often in the neck. - While present since childhood, its appearance is typically **cystic or multicystic** and does not usually have the distinct bag-of-worms texture or a central black spot described.

Question 1

A 60-year-old man presents with painless, progressive enlargement of the parotid gland. What is the most likely diagnosis?

Accepted Answer

Parotid gland tumor

Answer

Parotitis

Answer

Sialolithiasis

Answer

Mumps

Question 2

A patient with a pituitary tumor undergoes transsphenoidal surgery for tumor resection. Which anatomical structure serves as the surgical access route in this procedure?

Accepted Answer

Sphenoid sinus

Answer

Nasal septum

Answer

Maxillary sinus

Answer

Ethmoid sinus

Question 3

A middle-aged man with a swelling over the neck since childhood with the overlying skin not intact which had a bag or worm-like appearance with a black spot in the middle. What will be the diagnosis?

Accepted Answer

Plexiform neurofibroma

Answer

Sebaceous cyst

Answer

Carotid body tumor

Answer

Cystic hygroma

Question 4

What is the most likely diagnosis for the parotid mass with mixed consistency shown in the image?

Accepted Answer

Pleomorphic adenoma

Answer

Sebaceous cyst

Answer

Dermoid cyst

Answer

None of the options

Question 5

Preferred treatment for oral tongue carcinoma which infiltrates the local cortical bone is -

Accepted Answer

Subtotal glossectomy + selective neck dissection + mandibulectomy

Answer

Subtotal glossectomy alone

Answer

Subtotal glossectomy with selective neck dissection only

Answer

Total glossectomy with selective neck dissection and mandibulectomy

Question 6

For lower lip carcinoma of <1 cm in size, the treatment of choice will be:

Accepted Answer

Excision

Answer

Radiation

Answer

Chemotherapy

Answer

Radiation and chemotherapy

Question 7

In the context of oropharyngeal cancer, for which nodal status is Level III lymph node dissection indicated?

Accepted Answer

N2

Answer

N3

Answer

N0

Answer

N1

Question 8

Which surgical landmarks are used for locating the facial nerve?

Accepted Answer

All of the options

Answer

Tympano - mastoid suture

Answer

Tragal pointer

Answer

Posterior belly of digastric

Question 9

A 23-year-old male patient presents with midline swelling in the neck. The swelling moves with deglutition and protrusion of the tongue. What is the likely diagnosis?

Accepted Answer

Thyroglossal cyst

Answer

Brachial cyst

Answer

Plunging ranula

Answer

Dermoid cyst

Question 10

A middle-aged man presents with a swelling in the neck that has been present since childhood. The swelling has a bag or worm-like appearance and features a central black spot. Based on this description, what is the most likely diagnosis?

Accepted Answer

Plexiform neurofibroma

Answer

Cirsoid aneurysm

Answer

Varicocele

Answer

Lymphangioma

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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