Head and Neck Surgery

Head and Neck Surgery Indian Medical PG Question 1: In an accident case, after the arrival of medical team, all should be done in early management except;

• A. Glasgow coma scale
• B. Check BP (Correct Answer)
• C. Stabilization of cervical vertebrae
• D. Check Respiration

Head and Neck Surgery Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.

Head and Neck Surgery Indian Medical PG Question 2: A 55 year old male came with history of hoarseness of voice for which direct laryngoscopy was done and the lesion was biopsied to detect squamous cell carcinoma. He now requires investigation to detect extent of cartilage involvement, imaging of pre and paraglottic spaces and any extension to deep neck structures. Most appropriate investigation of choice will be:

• A. MRI (Correct Answer)
• B. CT Scan
• C. Repeat direct laryngoscopy under general anaesthesia
• D. Endo Ultrasound

Head and Neck Surgery Explanation: ***MRI*** - **MRI** is superior for evaluating **cartilage involvement** (especially thyroid cartilage), pre-epiglottic, and paraglottic space invasion due to its excellent **soft tissue contrast**. - It also helps in assessing **deep neck invasion**, perineural spread, and for identifying disease recurrence after radiation therapy. *CT Scan* - While CT can show bone and cartilage calcification, its ability to differentiate subtle **cartilage invasion** and **soft tissue involvement** in the pre-epiglottic and paraglottic spaces is inferior to MRI. - It involves **ionizing radiation** and may not provide as detailed information regarding the extent of soft tissue and marrow invasion. *Repeat direct laryngoscopy under general anaesthesia* - This is an **invasive procedure** primarily used for direct visualization, biopsy, and staging of superficial lesions or for therapeutic interventions. - It is not effective for evaluating the **depth of invasion** or spread to **deep neck structures**. *Endo Ultrasound* - **Endoscopic ultrasound (EUS)** is primarily used for evaluating gastrointestinal and sometimes tracheobronchial lesions for depth of invasion and nodal staging. - It is **not the primary imaging modality** for assessing the extent of laryngeal squamous cell carcinoma, especially for cartilage invasion or deep neck structures.

Head and Neck Surgery Indian Medical PG Question 3: What is Galen's anastomosis?

• A. Recurrent laryngeal nerve and external laryngeal nerve
• B. Internal laryngeal nerve and recurrent laryngeal nerve (Correct Answer)
• C. None of the options
• D. Recurrent laryngeal nerve and sympathetic trunk

Head and Neck Surgery Explanation: ***Internal laryngeal nerve and recurrent laryngeal nerve*** - **Galen's anastomosis** (also known as **ansa Galeni**) is the connection between the **internal laryngeal nerve** (a sensory branch of the superior laryngeal nerve) and the **recurrent laryngeal nerve** (motor branch of the vagus nerve). - This anastomosis occurs in the **laryngeal mucosa** and allows for communication between these two important nerves. - The **internal laryngeal nerve** provides **sensory innervation** to the larynx above the vocal cords, while the **recurrent laryngeal nerve** provides **motor innervation** to most intrinsic laryngeal muscles (except cricothyroid). - This anastomosis is clinically significant in understanding the complex innervation patterns of the larynx. *Recurrent laryngeal nerve and external laryngeal nerve* - While both nerves are branches of the vagus nerve and innervate laryngeal structures, this connection does not constitute **Galen's anastomosis**. - The recurrent laryngeal nerve innervates intrinsic laryngeal muscles (except cricothyroid), while the external laryngeal nerve innervates the **cricothyroid muscle** and is motor in nature. *None of the options* - This option is incorrect because the correct definition of **Galen's anastomosis** is provided in the first option. *Recurrent laryngeal nerve and sympathetic trunk* - While there may be sympathetic contributions to laryngeal innervation, this does not represent **Galen's anastomosis**. - The sympathetic trunk provides autonomic innervation but the specific named anastomosis refers to the connection between the internal laryngeal and recurrent laryngeal nerves.

Head and Neck Surgery Indian Medical PG Question 4: N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:

• A. Metastasis in a lymph node >6 cm (Correct Answer)
• B. Metastasis in lymph nodes >2 cm
• C. Metastasis in lymph nodes >5 cm
• D. None of the options

Head and Neck Surgery Explanation: ***Metastasis in a lymph node >6 cm*** - **N3a disease** in head and neck cancer staging (AJCC 8th edition) specifically refers to metastasis in a single lymph node larger than 6 cm in greatest dimension **without extranodal extension (ENE)**. - This applies to oral cavity, oropharynx (HPV-negative), hypopharynx, and larynx cancers. - **Note:** N3 staging also includes **N3b** (metastasis in any node with clinically overt ENE), but this question specifically asks about N3a criteria. *Metastasis in lymph nodes >2 cm* - Lymph nodes in the 2-3 cm range typically fall within **N1 or N2a categories**, depending on laterality and number of involved nodes. - **N3a disease** requires a single lymph node to exceed 6 cm in greatest dimension without ENE. *Metastasis in lymph nodes >5 cm* - A lymph node between 3-6 cm is usually classified as **N2 disease** (N2a if single ipsilateral ≤6 cm, N2b if multiple ipsilateral ≤6 cm, N2c if bilateral or contralateral ≤6 cm). - To be classified as **N3a**, the lymph node must be **>6 cm** without extranodal extension. *None of the options* - This option is incorrect because the first option accurately describes the size criterion for **N3a TNM staging** in head and neck tumors according to AJCC 8th edition guidelines. - While N3 staging has two subcategories (N3a and N3b), the size criterion of >6 cm correctly defines N3a disease.

Head and Neck Surgery Indian Medical PG Question 5: Identify the investigation being carried out in the image.

• A. Fluoroscopy
• B. X-ray after alkali ingestion
• C. X-ray after acid ingestion
• D. Barium Swallow (Correct Answer)

Head and Neck Surgery Explanation: ***Barium Swallow*** - The image shows a contrast material, characteristic of **barium**, flowing through the esophagus, captured as a sequence of X-ray images, which is the definition of a barium swallow study. - This **dynamic imaging** allows for evaluation of swallowing function and esophageal motility. *Fluoroscopy* - While a barium swallow uses **fluoroscopy** to visualize the movement of barium, fluoroscopy itself is the technique, not the specific investigation being performed. The image depicts the result of a specific type of fluoroscopic examination. - Fluoroscopy is a general term for real-time X-ray imaging, whereas "Barium Swallow" specifies the type of study being done on the upper GI tract. *X-ray after alkali ingestion* - This scenario would typically involve viewing the effects of **corrosive injury** to the esophagus, which would appear as mucosal damage, narrowing, or perforation. The image does not show these features; instead, it shows smooth passage of contrast. - There is no visible evidence of an acute or chronic injury pattern consistent with **alkali ingestion**, which often leads to severe burns or strictures. *X-ray after acid ingestion* - Similar to alkali ingestion, acid ingestion also causes **corrosive injury**, typically affecting the stomach more severely than the esophagus. The image does not demonstrate these pathological changes. - The smooth, unobstructed flow of contrast in multiple frames is indicative of normal esophageal function rather than the sequelae of corrosive ingestion.

Head and Neck Surgery Indian Medical PG Question 6: In an emergency tracheostomy, which structures are least likely to be damaged?

• A. Isthmus of the thyroid
• B. Thyroid ima
• C. Inferior thyroid vein
• D. Inferior thyroid artery (Correct Answer)

Head and Neck Surgery Explanation: ***Inferior thyroid artery*** - The **inferior thyroid artery** is typically located deep and lateral to the trachea, arising from the thyrocervical trunk and approaching the thyroid gland posteriorly [1]. - During emergency tracheostomy, the incision is made in the midline over the 2nd-4th tracheal rings, whereas this artery runs laterally at a lower level (typically around the 6th tracheal ring). - Its **deep and lateral anatomical position** makes it the least vulnerable structure among the options during a standard midline tracheostomy incision [1]. *Isthmus of the thyroid* - The **isthmus of the thyroid gland** crosses the trachea anteriorly, typically overlying the 2nd, 3rd, and 4th tracheal rings. - It lies directly in the path of an emergency tracheostomy incision and is frequently encountered, often requiring division or retraction to access the trachea. - This structure is **highly likely to be damaged** during the procedure. *Thyroid ima artery* - The **thyroid ima artery** is an inconsistent vessel, present in approximately 3-10% of individuals, arising from the brachiocephalic trunk or aortic arch. - When present, it ascends in the **midline** to supply the inferior pole of the thyroid gland, placing it directly in the path of the tracheostomy incision. - This vessel is **highly susceptible to injury** when present, potentially causing significant arterial bleeding. *Inferior thyroid vein* - The **inferior thyroid veins** drain the thyroid gland and form a venous plexus anterior to the trachea, superficial to the thyroid isthmus [1]. - This plexus lies in the **superficial surgical field** and is prone to injury during the midline cervical incision for tracheostomy. - Damage to these veins commonly occurs and can lead to significant venous bleeding [1].

Head and Neck Surgery Indian Medical PG Question 7: Supraomohyoid dissection is a type of?

• A. Selective neck dissection (Correct Answer)
• B. Modified radical neck dissection
• C. Radical neck dissection
• D. Posterolateral dissection

Head and Neck Surgery Explanation: ***Selective neck dissection*** - **Supraomohyoid dissection** specifically refers to a type of selective neck dissection, characterized by the removal of lymph node levels **I, II, and III**. - This procedure is commonly performed for early-stage oral cavity cancers due to their typical lymphatic spread patterns. *Modified radical neck dissection* - This dissection preserves one or more **non-lymphatic structures** (e.g., sternocleidomastoid muscle, internal jugular vein, spinal accessory nerve) that are typically removed in a radical neck dissection. - It involves a broader range of lymph node levels (typically **I-V**) compared to a supraomohyoid dissection. *Radical neck dissection* - This is a more extensive procedure involving the removal of all lymph node groups (levels **I-V**), along with the **sternocleidomastoid muscle**, **internal jugular vein**, and **spinal accessory nerve**. - It is reserved for advanced neck disease due to its significant morbidity. *Posterolateral dissection* - **Posterolateral neck dissection** is a term not commonly used within the standard classification of neck dissections (radical, modified radical, selective). - Lymphatic dissection is typically categorized based on anatomical levels rather than a general directional term like posterolateral.

Head and Neck Surgery Indian Medical PG Question 8: In sepsis due to cholecystitis, which is the initial anatomical structure typically involved?

• A. Left lobe of liver
• B. Hepatic portal vein & IVC
• C. Quadrate lobe of liver (Correct Answer)
• D. Right lobe of liver

Head and Neck Surgery Explanation: ***Quadrate lobe of liver*** - The **gallbladder fossa** is located on the visceral surface of the liver, directly bordered by the **quadrate lobe** (Couinaud segment IV). - In cases of cholecystitis progressing to sepsis with hepatic involvement, the **quadrate lobe** is the initial anatomical structure affected due to its **direct anatomical contact** with the gallbladder. - Pericholecystic inflammation and abscess formation typically extend first into the quadrate lobe parenchyma before involving other hepatic segments. *Right lobe of liver* - While the gallbladder is anatomically related to the right lobe, the **quadrate lobe** (though functionally part of the left hepatic territory) is the structure in **immediate contact** with the gallbladder fossa. - The right lobe proper (segments V-VIII) may be involved subsequently, but it is not the **initial** site of direct inflammatory spread. *Hepatic portal vein & IVC* - The **hepatic portal vein** and **inferior vena cava (IVC)** are not in direct anatomical contact with the gallbladder. - These vascular structures may be affected in advanced stages through septic thrombophlebitis (**pylephlebitis**) or hematogenous spread, but not as the **initial** anatomical site of local extension. *Left lobe of liver* - The **left lobe** (segments II and III) is anatomically distant from the gallbladder, separated by the falciform ligament and other structures. - It would not be the initial site of direct inflammatory spread from cholecystitis.

Head and Neck Surgery Indian Medical PG Question 9: A 56-year-old male came with acute onset breathlessness and found to have pneumothorax. The resident doctor decided to insert an intercostal drain. Which one of the following sites is suitable for such a procedure?

• A. Petit's triangle
• B. Hesselbach's triangle
• C. Triangle of auscultation
• D. Triangle of safety (Correct Answer)

Head and Neck Surgery Explanation: ***Triangle of safety*** - The **triangle of safety** is the universally accepted site for safe **intercostal drain (chest tube)** insertion to treat **pneumothorax**. - Its boundaries help avoid injury to vital organs; it is bordered by the **anterior border of the latissimus dorsi**, the **lateral border of the pectoralis major**, and the **fifth intercostal space**. *Petit's triangle* - This anatomical landmark, also known as the **lumbar triangle**, is located in the **lumbar region** of the back. - It defines a weaker area in the abdominal wall and is a common site for **lumbar hernias**, not chest tube insertion for pneumothorax. *Hesselbach's triangle* - This triangle is located in the **groin region** and is an important anatomical landmark for **inguinal hernias**. - It is bordered by the inferior epigastric vessels, the lateral border of the rectus abdominis, and the inguinal ligament, and is entirely unrelated to chest procedures. *Triangle of auscultation* - The **triangle of auscultation** is a small region of the back, bordered by the **latissimus dorsi**, **trapezius**, and **medial border of the scapula**. - It is a thinner area of musculature, making it an ideal location for **listening to breath sounds** with a stethoscope, but it is not used for invasive procedures like chest tube insertion.

Head and Neck Surgery Indian Medical PG Question 10: Most commonly ruptured organ in blunt trauma to abdomen is:

• A. Liver
• B. Spleen (Correct Answer)
• C. Kidney
• D. Adrenals

Head and Neck Surgery Explanation: ***Spleen*** - The **spleen** is the most commonly injured organ in **blunt abdominal trauma** (40-55% of cases) due to its superficial location in the left upper quadrant and its relatively fragile, highly vascular parenchyma. - Its anatomical position, without significant muscular or bony protection anteriorly, makes it vulnerable to compressive and shearing forces during blunt impacts. - Typically presents with left upper quadrant pain, left shoulder pain (Kehr's sign), and signs of hypovolemic shock. *Liver* - While the **liver** is the second most commonly injured organ in blunt abdominal trauma (35-45% of cases), it is less frequently ruptured than the spleen. - Its larger size and more protected position by the rib cage offer some degree of shielding compared to the spleen. - Presents with right upper quadrant pain and peritoneal signs. *Kidney* - **Kidney injuries** are less common than splenic or hepatic injuries in blunt abdominal trauma, requiring significant force due to their retroperitoneal location and protection by the back muscles and lower ribs. - Renal trauma is usually associated with flank pain and hematuria. - Protected retroperitoneal position makes injury less frequent. *Adrenals* - **Adrenal gland injuries** are extremely rare in blunt abdominal trauma, typically occurring only with severe, high-energy impact and often in conjunction with other significant organ damage. - Their small size and deep retroperitoneal location make them highly protected.

Head and Neck Surgery Flashcard 1 of 10

Question: The commonest complication of Caldwell Luc operation is _____

Answer: infra orbital nerve injury

Head and Neck Surgery Flashcard 2 of 10

Question: In subtype 1 of modified radical neck dissection, what structures are preserved?_____

Answer: spinal accessory nerve

Head and Neck Surgery Flashcard 3 of 10

Question: _____ operation is used for squamous cell carcinoma of the oral cavity

Answer: Commando

Head and Neck Surgery Flashcard 4 of 10

Question: _____ position is used in tonsillectomy, adenoidectomy and tracheostomy

Answer: Rose's

Head and Neck Surgery Flashcard 5 of 10

Question: Ethmoidal vessels are exposed in the medial wall of the orbit by an external ethmoid (_____) incision.

Answer: Lynch

Head and Neck Surgery Flashcard 6 of 10

Question: Thyroid isthumus is divided in _____ tracheostomy

Answer: Mid (level)

Head and Neck Surgery Flashcard 7 of 10

Question: In subtype 2 of modified radical neck dissection, what structures are preserved?_____

Answer: SAN and IJV

Head and Neck Surgery Flashcard 8 of 10

Question: _____ system of tooth charting:

Answer: Universal

Head and Neck Surgery Flashcard 9 of 10

Question: Name the following forceps: _____

Answer: Citelli's forceps

Head and Neck Surgery Flashcard 10 of 10

Question: Fenestrations in the tracheostomy tube are important for _____

Answer: phonation