Head and Neck Surgery Practice Questions

Q: All of the following statements regarding stones in the submandibular gland are true except one:

Majority of submandibular stones are radiolucent. ***Majority of submandibular stones are radiolucent*** - This statement is **incorrect** because submandibular stones (sialoliths) are typically composed of **calcium phosphate and calcium carbonate**, making them **radiopaque** on plain radiographs. - Approximately **80-90%** of submandibular stones are radiopaque and visible on X-rays. - Only 10-20% are radiolucent, making this the false statement in this "except" question. *80% of stones occur in the submandibular gland* - This statement is **true**; the submandibular gland is the most common site for salivary stones, accounting for **80-92%** of all sialoliths. - This high prevalence is due to Wharton's duct being longer and more tortuous, gravity-dependent positioning, and the alkaline mucinous nature of submandibular saliva. *Patient presents with acute pain and swelling in the region of the submandibular gland* - This is **true** and represents the classic presentation of sialolithiasis. - Pain and swelling typically **worsen with eating** (when salivary flow increases) and may partially subside between meals. - This is often called "mealtime syndrome" or prandial pain. *The hypoglossal nerve is at risk during submandibular gland excision* - This statement is **true**. During submandibular gland excision, the **hypoglossal nerve (CN XII)** runs close to the superior aspect of the gland and can be injured. - Other nerves at risk include the **marginal mandibular branch of the facial nerve** (most commonly injured, causing lower lip weakness) and the **lingual nerve** (causing tongue numbness). - Hypoglossal nerve injury results in tongue deviation toward the affected side and difficulties with speech and swallowing.

Q: High tracheostomy is done in which one of the following conditions?

Tracheal stenosis. ***Tracheal stenosis*** - A **high tracheostomy** is performed when there is **lower tracheal stenosis** or obstruction, requiring placement of the tracheostomy stoma **above the stenotic segment**. - This approach ensures that the **tracheostomy tube** bypasses the narrowed portion of the trachea and provides a patent airway. - The level of tracheostomy is chosen based on the location of the pathology - high tracheostomy for lower pathology, and vice versa. *Laryngeal cancer* - In **laryngeal cancer**, a **low tracheostomy** is typically preferred, not a high one. - A high tracheostomy in laryngeal malignancy is generally **contraindicated** due to the risk of tumor seeding and interference with surgical planning. - The tracheostomy should be placed **away from the tumor site** and below the pathology, especially if laryngectomy is planned. *Severe asthma exacerbation* - **Severe asthma exacerbation** rarely requires a tracheostomy; endotracheal intubation and mechanical ventilation are the standard initial management. - If prolonged ventilatory support is needed, a **standard tracheostomy** (not high) would be performed. - There is no specific indication for high tracheostomy placement in asthma. *Vocal cord dysfunction* - **Vocal cord dysfunction (VCD)** involves paradoxical vocal cord movement and is typically managed with **conservative measures** including speech therapy and breathing exercises. - VCD does not cause structural obstruction requiring surgical airway intervention. - Tracheostomy, especially high tracheostomy, has no role in the management of VCD.

Q: What is the purpose of tilting the cast during surveying?

Obtain a favorable path of insertion. ***Obtain a favorable path of insertion*** - Tilting the cast allows the dental professional to analyze the various **undercuts** and **interferences** on the teeth and surrounding tissues. - By adjusting the cast's orientation, an **optimal path of insertion** can be identified, minimizing interferences and ensuring the proper seating of a dental prosthesis. *Achieve maximum guiding planes* - While guiding planes are important for stability and resistance to displacement, the primary purpose of cast tilting is not to maximize them directly. - **Guiding planes** are prepared on the teeth to create parallel surfaces, which are then evaluated and utilized after the optimal path of insertion is determined. *Create undercuts* - The purpose of tilting is to identify and utilize existing **undercuts** for retention, not to create them. - **Undercuts** are naturally present areas below the height of contour, and tilting helps in selecting the most appropriate ones for clasp engagement. *Obtain retention* - While tilting the cast ultimately contributes to effective **retention** by identifying suitable undercuts, it is part of the broader goal of establishing a functional path of insertion. - **Retention** is achieved by the engagement of retentive clasps into specific undercuts that are identified during the surveying process, after determining the path of insertion.

Q: Which of the following swellings moves on protrusion of the tongue?

Thyroglossal cyst. ***Thyroglossal cyst*** - A **thyroglossal cyst** is a remnant of the **thyroglossal duct**, which connects the thyroid gland to the tongue during embryonic development. - Due to its embryological connection with the foramen cecum at the base of the tongue, it moves **superiorly with tongue protrusion** and swallowing. *Branchial cyst* - A **branchial cyst** is a congenital anomaly resulting from the incomplete obliteration of branchial arches, typically presenting laterally in the neck. - It does not have an anatomical connection to the tongue and therefore **does not move with tongue protrusion**. *Ranula* - A **ranula** is a mucocele found on the floor of the mouth, usually caused by obstruction or rupture of a salivary gland duct. - It is located entirely within the oral cavity or submandibular space and **does not move with tongue protrusion**. *Cyst in hyoid bone* - A cyst within the **hyoid bone** itself is exceedingly rare; more commonly, a thyroglossal cyst can be intimately associated with or pass through the hyoid bone. - A cyst within the bone structure would generally not exhibit mobility with tongue protrusion.

Q: Which of the following is a midline neck swelling?

Thyroglossal cyst. ***Thyroglossal cyst*** - A thyroglossal cyst is a congenital anomaly arising from the **remnant of the thyroglossal duct**, which is the embryonic path of the thyroid gland's descent. - It characteristically presents as a **midline neck swelling**, often just below the hyoid bone, and typically **moves upwards with tongue protrusion**. *Carotid body tumor* - A carotid body tumor, or **chemodectoma**, is usually located in the **lateral neck**, specifically at the carotid bifurcation. - It is typically **pulsatile** and has a characteristic **bruit**, with limited mobility in the horizontal but not vertical plane (Fontaine's sign). *Branchial cyst* - A branchial cyst is a congenital lesion that typically presents in the **lateral neck**, usually anterior to the sternocleidomastoid muscle. - It arises from **incomplete obliteration of the branchial arches** during embryonic development. *Cystic hygroma* - A cystic hygroma is a **lymphatic malformation** that commonly presents as a **soft, compressible mass** in the **posterolateral neck**. - These are typically **transilluminable** and can be quite large, often visible at birth or in early childhood.

Q: Tracheostomy is typically performed between which tracheal rings?

2nd-3rd tracheal rings. ***2nd-3rd tracheal rings*** - The space between the **2nd and 3rd tracheal rings** is the **most common and preferred site** for performing a tracheostomy. - This location provides optimal balance between ease of access and safety, minimizing risk of damage to the **cricoid cartilage** superiorly while avoiding larger vascular structures inferiorly. - This standard placement reduces complications including subglottic stenosis and major vessel injury. - Most surgical textbooks and guidelines recommend this as the **ideal anatomical site** for elective tracheostomy. *1st tracheal ring* - Performing a tracheostomy at the level of the **first tracheal ring** is generally avoided as it is too high and carries significant risk of damaging the **cricoid cartilage** and affecting the **larynx**. - This high placement can lead to **subglottic stenosis** and voice complications. *5th-6th tracheal rings* - A tracheostomy performed between the **5th and 6th tracheal rings** is considered too low and increases the risk of complications. - This deep approach may encounter surrounding vascular structures and is generally not recommended for standard tracheostomy procedures. *7th-8th tracheal rings* - Performing a tracheostomy between the **7th and 8th tracheal rings** is too low and increases the risk of entering the **mediastinum** or damaging the **innominate artery** or other major vessels. - This deeper dissection can lead to significant bleeding and other serious complications.

Q: Which of the following is not a boundary of Jackson's triangle used in tracheotomy?

Outer border of sternocleidomastoid. ***Outer border of sternocleidomastoid*** - Jackson's triangle, or the **surgical safety triangle for tracheotomy**, is defined by the **upper border of the sternal manubrium (suprasternal notch)**, the **lower border of the thyroid cartilage**, and the **medial borders of the sternocleidomastoid muscles**. - The **outer border of the sternocleidomastoid** muscle is not one of the boundaries of this specific surgical triangle. *Suprasternal notch* - The **suprasternal notch** (upper border of the sternal manubrium) forms the **inferior boundary** of Jackson's triangle. - This anatomical landmark is crucial for correctly identifying the cricoid cartilage and trachea for a safe tracheotomy. *Lower edge thyroid cartilage* - The **lower edge of the thyroid cartilage** forms the **superior boundary** of Jackson's triangle. - Palpation of this structure helps to locate the cricoid cartilage and the tracheal rings below it. *Inner border of sternocleidomastoid* - The **inner (medial) borders of the sternocleidomastoid muscles** form the two **lateral boundaries** of Jackson's triangle. - These muscles delineate the central neck region where the trachea is accessed during a tracheotomy.

Q: A patient presents with a cheek cancer of 2.5 cm size, which is close to and involves the alveolus, and is associated with a single mobile cervical lymph node of 6 cm size. What is the TNM staging?

T4 N2. ***T4 N2*** - The primary tumor involving the **alveolus (cortical bone invasion)** is classified as **T4a** regardless of size according to AJCC TNM staging for oral cavity cancers. - A single mobile ipsilateral cervical lymph node of **6 cm** is classified as **N2a** (single ipsilateral node, 3-6 cm in greatest dimension). - Therefore, the correct staging is **T4 N2**. *T3 N2* - **T3 classification is incorrect** as alveolar involvement (cortical bone invasion) automatically upgrades the tumor to T4a. - While N2 is correct for a single 6 cm node, the T-stage is underestimated. *T4 N3* - While **T4 is correct** due to alveolar bone involvement, **N3 is incorrect**. - **N3a requires lymph nodes >6 cm** (greater than 6 cm), not equal to 6 cm. - A single 6 cm node falls within the N2a category (3-6 cm range). *T3 N3* - **Both T3 and N3 are incorrect** for this presentation. - Alveolar involvement mandates T4 staging, and a 6 cm node is N2a, not N3.

Q: A 25-year-old woman is concerned about a lump on the left side of her neck that has remained the same size for the past year. Physical examination shows a painless, movable, 3-cm nodule beneath the skin of the left lateral neck just above the level of the thyroid cartilage. There are no other remarkable findings. Fine-needle aspiration of the mass is performed. The pathology report notes the presence of cellular debris. Based on the clinical presentation and pathology findings, which of the following terms best describes this nodule?

Branchial cyst. ***Branchial cyst*** - A **branchial cyst** typically presents as a **painless, movable lateral neck mass** in young adults, often just anterior to the sternocleidomastoid muscle at the junction of the upper and middle third of the neck. - The presence of **cellular debris** in the fine-needle aspiration (FNA) is consistent with the benign, fluid-filled nature of a branchial cyst, which contains watery or mucoid material with desquamated epithelial cells. - The **stable size over one year** supports a benign congenital lesion rather than malignancy. *Metastatic thyroid carcinoma* - This would typically present as a **hard, fixed mass**, possibly associated with other symptoms like **hoarseness or dysphagia**. - FNA would show **malignant follicular cells** consistent with thyroid origin, not just cellular debris. - A metastatic lesion would be unlikely to remain stable in size for a year. *Thyroglossal duct cyst* - This is the most common **midline neck mass** in children and young adults, typically located at or near the **midline** between the base of tongue and thyroid gland. - It characteristically **moves with swallowing and tongue protrusion**, unlike branchial cysts. - The **lateral location** in this case makes thyroglossal duct cyst incorrect. *Mucoepidermoid tumor* - This is a **malignant salivary gland tumor** that can occur in the parotid or submandibular regions. - It usually presents as a **firm, progressively growing mass** and would not remain stable at 3 cm for a year. - FNA would show **malignant epithelial and mucous-producing cells**, not just bland cellular debris.

Q: Which of the following statements about Ludwig's angina is true?

It involves both submandibular and sublingual spaces.. ***It involves both submandibular and sublingual spaces.*** - Ludwig's angina is a rapidly spreading, **bilateral cellulitis** involving the **submandibular, sublingual, and submental spaces**. - Its involvement of these spaces can lead to a characteristic **"brawny" induration** of the neck and elevation of the tongue. - This is the defining anatomical characteristic of Ludwig's angina. *It is primarily a viral infection.* - Ludwig's angina is a **bacterial infection**, not viral. - The most common causative organisms are **oral flora**, including Streptococcus, Staphylococcus, and anaerobes. - **Dental infections** (particularly from the second and third mandibular molars) are the most common source (80-90% of cases). *It is usually unilateral.* - Ludwig's angina is characteristically a **bilateral infection** of the floor of the mouth and neck spaces. - Unilateral involvement would suggest a more localized infection, such as an **abscess**, rather than the diffuse cellulitis of Ludwig's angina. *It spreads by lymphatics.* - Ludwig's angina is a **diffuse cellulitis** that spreads via continuity through **fascial planes** and connective tissues, rather than primarily through the lymphatic system. - The absence of significant **lymphadenopathy** is a key differentiating feature from other neck infections.

Question 1

All of the following statements regarding stones in the submandibular gland are true except one:

Accepted Answer

Majority of submandibular stones are radiolucent

Answer

Patient presents with acute pain and swelling in the region of the submandibular gland

Answer

80% of stones occur in the submandibular gland

Answer

The hypoglossal nerve is at risk during submandibular gland excision

Question 2

High tracheostomy is done in which one of the following conditions?

Accepted Answer

Tracheal stenosis

Answer

Laryngeal cancer

Answer

Severe asthma exacerbation

Answer

Vocal cord dysfunction

Question 3

What is the purpose of tilting the cast during surveying?

Accepted Answer

Obtain a favorable path of insertion

Answer

Achieve maximum guiding planes

Answer

Create undercuts

Answer

Obtain retention

Question 4

Which of the following swellings moves on protrusion of the tongue?

Accepted Answer

Thyroglossal cyst

Answer

Branchial cyst

Answer

Ranula

Answer

Cyst in hyoid bone

Question 5

Which of the following is a midline neck swelling?

Accepted Answer

Thyroglossal cyst

Answer

Carotid body tumor

Answer

Branchial cyst

Answer

Cystic hygroma

Question 6

Tracheostomy is typically performed between which tracheal rings?

Accepted Answer

2nd-3rd tracheal rings

Answer

7th-8th tracheal rings

Answer

5th-6th tracheal rings

Answer

1st tracheal ring

Question 7

Which of the following is not a boundary of Jackson's triangle used in tracheotomy?

Accepted Answer

Outer border of sternocleidomastoid

Answer

Suprasternal notch

Answer

Lower edge thyroid cartilage

Answer

Inner border of sternocleidomastoid

Question 8

A patient presents with a cheek cancer of 2.5 cm size, which is close to and involves the alveolus, and is associated with a single mobile cervical lymph node of 6 cm size. What is the TNM staging?

Accepted Answer

T4 N2

Answer

T3 N2

Answer

T3 N3

Answer

T4 N3

Question 9

A 25-year-old woman is concerned about a lump on the left side of her neck that has remained the same size for the past year. Physical examination shows a painless, movable, 3-cm nodule beneath the skin of the left lateral neck just above the level of the thyroid cartilage. There are no other remarkable findings. Fine-needle aspiration of the mass is performed. The pathology report notes the presence of cellular debris. Based on the clinical presentation and pathology findings, which of the following terms best describes this nodule?

Accepted Answer

Branchial cyst

Answer

Metastatic thyroid carcinoma

Answer

Thyroglossal duct cyst

Answer

Mucoepidermoid tumor

Question 10

Which of the following statements about Ludwig's angina is true?

Accepted Answer

It involves both submandibular and sublingual spaces.

Answer

It is usually unilateral.

Answer

It spreads by lymphatics.

Answer

It is primarily a viral infection.

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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