Neck Practice Questions

Q: A 67-year-old female presents with severe neck swelling. An MRI reveals an abscess in the middle of the posterior cervical triangle of the right side, which is surgically removed. Postoperatively, she experiences shoulder drooping and difficulty raising her right hand above her head. Which nerve has most likely been iatrogenically injured?

Accessory. ### Explanation **Correct Option: A. Accessory Nerve (CN XI)** The **Spinal Accessory Nerve** is the most commonly injured nerve during surgical procedures in the **posterior triangle of the neck** [1]. It follows a superficial and vulnerable course, emerging from the posterior border of the Sternocleidomastoid (SCM) muscle and crossing the posterior triangle to supply the **Trapezius**. * **Mechanism of Injury:** The Trapezius is responsible for shrugging the shoulders and assisting the Serratus Anterior in rotating the scapula to raise the arm above the horizontal (90°) plane. * **Clinical Presentation:** Injury results in **shoulder drooping**, winging of the scapula, and an inability to abduct the arm above the head [1]. **Incorrect Options:** * **B. Ansa cervicalis:** Located deep to the SCM within the carotid triangle; it supplies the infrahyoid (strap) muscles. Injury would not affect shoulder movement. * **C. Facial Nerve (CN VII):** Primarily supplies muscles of facial expression. While the cervical branch supplies the Platysma, it does not influence shoulder elevation. * **D. Hypoglossal Nerve (CN XII):** Located in the submandibular and carotid triangles; it supplies the intrinsic and extrinsic muscles of the tongue. Injury leads to tongue deviation, not shoulder weakness. **NEET-PG High-Yield Pearls:** * **Surface Anatomy:** The Accessory nerve enters the posterior triangle at the junction of the upper 1/3rd and middle 1/3rd of the posterior border of the SCM. * **The "Carefree" vs. "Careful" Zone:** The area above the accessory nerve in the posterior triangle is relatively safe, while the area below it contains the brachial plexus and is considered the "danger zone." * **Differential:** If the patient can raise the arm to 90° but not above, think **Serratus Anterior** (Long Thoracic Nerve) or **Trapezius** (Accessory Nerve). If they cannot initiate abduction, think **Supraspinatus**.

Q: What is the correct description of the vertebral artery?

Passes through the C6 foramen transversarium.. ### Explanation The vertebral artery is a vital branch of the **first part of the subclavian artery**. It is traditionally divided into four segments (V1–V4). **Why Option C is Correct:** The vertebral artery (V1 segment) ascends and enters the **foramen transversarium of the C6 vertebra**. It then continues superiorly through the foramina of C5 to C1. Crucially, it **bypasses the C7 foramen transversarium**, which usually only contains small accessory vertebral veins. **Analysis of Incorrect Options:** * **Option A:** While it arises from the first part of the subclavian artery, it lies **medial** to the scalenus anterior muscle, not posterior to it. * **Option B:** The artery actually lies **anterior** to the inferior thyroid artery as it ascends toward the C6 transverse process. * **Option D:** After exiting the C1 foramen transversarium, the artery winds **posteriorly** around the lateral mass of the atlas (lying in the groove on the posterior arch) and then enters the skull through the **foramen magnum**. While this sounds correct, Option C is the most definitive anatomical landmark tested in NEET-PG regarding its entry point into the cervical spine. **High-Yield Clinical Pearls:** * **Suboccipital Triangle:** The V3 segment of the vertebral artery is found in the floor of the suboccipital triangle. * **Basilar Artery:** The two vertebral arteries unite at the lower border of the **pons** to form the basilar artery. * **Wallenberg Syndrome:** Occlusion of the PICA (a branch of the V4 segment) or the vertebral artery itself leads to Lateral Medullary Syndrome.

Q: Which of the following statements is NOT true about the superior laryngeal nerve?

It supplies the larynx below the vocal cords.. The **Superior Laryngeal Nerve (SLN)** is a branch of the Vagus nerve (CN X) that divides into Internal and External branches [1]. Understanding its sensory and motor distribution is high-yield for NEET-PG. ### **Explanation of the Correct Answer** **Option B is False (Correct Answer):** The SLN (specifically the internal laryngeal branch) provides sensory innervation to the larynx **above the level of the vocal cords**. The area **below the vocal cords** is supplied by the **Recurrent Laryngeal Nerve (RLN)** [1]. This anatomical division is a frequent exam focus. ### **Analysis of Other Options** * **Option A:** The internal laryngeal nerve is purely sensory. Blocking this nerve (often done for awake intubations) successfully anesthetizes the laryngeal mucosa down to the level of the vocal folds. * **Options C & D:** These describe the same anatomical pathway. The **Internal Laryngeal Nerve**, along with the superior laryngeal artery, pierces the **thyrohyoid membrane**. This membrane spans the gap **between the thyroid cartilage and the hyoid bone**. ### **NEET-PG High-Yield Pearls** 1. **Internal Laryngeal Nerve:** Sensory above vocal cords; pierces thyrohyoid membrane; mediates the **afferent** limb of the cough reflex [1]. 2. **External Laryngeal Nerve:** Purely motor; supplies only the **Cricothyroid muscle** (the "tenser" of vocal cords). It is closely related to the Superior Thyroid Artery. 3. **Recurrent Laryngeal Nerve:** Sensory **below** vocal cords; motor to all intrinsic muscles of the larynx **except** the cricothyroid [1]. It is closely related to the Inferior Thyroid Artery. 4. **Clinical Correlation:** Injury to the External Laryngeal Nerve during thyroidectomy leads to a weak, husky voice and loss of high-pitched tones [2].

Q: A patient developed recurrent laryngeal nerve palsy during thyroid surgery. Which of the following laryngeal muscles is/are affected?

All. The **Recurrent Laryngeal Nerve (RLN)**, a branch of the Vagus nerve (CN X), provides motor innervation to almost all the intrinsic muscles of the larynx. The only exception is the **Cricothyroid muscle**, which is supplied by the External Laryngeal Nerve. 1. **Why "All" is correct:** The RLN supplies all intrinsic muscles of the larynx except the cricothyroid. This includes: * **Posterior cricoarytenoid:** The only abductor of the vocal cords (the "safety muscle"). * **Lateral cricoarytenoid:** The primary adductor. * **Thyroarytenoid (and Vocalis):** Relaxes the vocal cords. * **Interarytenoid (Transverse and Oblique):** Closes the posterior glottis. [1] Since the RLN supplies all these muscles, a palsy during thyroid surgery will affect all of them. Damage might result in a cord that remains in a midline position or paramedian position. [2] 2. **Analysis of Options:** * **Option A, B, and C:** While each of these muscles is individually affected, they are all supplied by the RLN. Therefore, selecting only one would be incomplete. **High-Yield Clinical Pearls for NEET-PG:** * **The "Safety Muscle":** The Posterior Cricoarytenoid is the only muscle that opens (abducts) the vocal cords. Bilateral RLN injury leads to respiratory distress because the cords cannot abduct. [2] * **Semon’s Law:** In progressive RLN lesions, the abductor fibers (Posterior cricoarytenoid) are more susceptible and paralyzed earlier than the adductor fibers. * **Anatomical Course:** The **Right RLN** hooks around the Right Subclavian Artery, while the **Left RLN** hooks around the Arch of Aorta. [1] * **Thyroid Surgery:** The RLN is most vulnerable near the **Ligament of Berry** and where it crosses the **Inferior Thyroid Artery**. [3]

Q: Which of the following is NOT an elastic laryngeal cartilage?

Thyroid. ### Explanation The laryngeal cartilages are classified into two types based on the histological nature of their matrix: **Hyaline** and **Elastic**. **1. Why Thyroid is the Correct Answer:** The **Thyroid cartilage** is composed of **hyaline cartilage**. Hyaline cartilages have a tendency to undergo **calcification and ossification** as a person ages (usually starting after age 25). Other hyaline cartilages in the larynx include the **Cricoid** and the **base of the Arytenoid** cartilages. **2. Analysis of Incorrect Options (Elastic Cartilages):** The elastic cartilages of the larynx contain abundant elastic fibers, providing flexibility. Crucially, **elastic cartilages do not calcify with age.** * **Epiglottis (Option A):** A leaf-shaped elastic cartilage that prevents food from entering the larynx. * **Corniculate (Option B):** Small, conical elastic nodules situated atop the arytenoid cartilages. * **Cuneiform (Option C):** Rod-shaped elastic cartilages located within the aryepiglottic folds. * *Note:* The **vocal process** and **apex** of the Arytenoid are also elastic. **3. NEET-PG High-Yield Pearls:** * **Mnemonic for Elastic Cartilages:** "**E**very **C**loud **C**ontains **A**ir" (**E**piglottis, **C**orniculate, **C**uneiform, **A**pical/vocal process of Arytenoid). * **Paired vs. Unpaired:** * *Unpaired:* Thyroid, Cricoid, Epiglottis. * *Paired:* Arytenoid, Corniculate, Cuneiform. * **Clinical Significance:** Because the Thyroid and Cricoid cartilages are hyaline, they become visible on X-rays in older adults due to calcification, which can sometimes be mistaken for foreign bodies.

Q: A person receives a shallow knife wound just behind the sternocleidomastoid muscle and about 1 1/2 inches above the clavicle. There is an immediate numbness of the skin below the wound and over the acromion and clavicle. Which nerve is most likely severed?

Supraclavicular nerve. ### Explanation **Correct Option: C. Supraclavicular nerve** The clinical presentation describes a wound at the **nerve point of the neck** (Erb’s point). This point is located at the posterior border of the sternocleidomastoid (SCM) muscle, approximately at its midpoint. From here, the cutaneous branches of the cervical plexus emerge. The **supraclavicular nerves (C3, C4)** descend from this point, passing deep to the platysma and crossing the clavicle to provide sensory innervation to the skin over the **clavicle, the acromion (top of the shoulder), and the upper part of the pectoral region**. A wound 1.5 inches above the clavicle behind the SCM directly intercepts these descending fibers, leading to the described numbness. **Analysis of Incorrect Options:** * **A. Greater auricular nerve (C2, C3):** This nerve ascends vertically across the SCM toward the parotid gland. It supplies the skin over the angle of the mandible and the lower part of the auricle. * **B. Lesser occipital nerve (C2):** This nerve ascends along the posterior border of the SCM to supply the scalp behind the auricle. * **D. Suprascapular nerve:** This is a **motor and sensory nerve** arising from the upper trunk of the brachial plexus. It travels deep to the clavicle to supply the supraspinatus and infraspinatus muscles and the shoulder joint; it does not provide cutaneous innervation to the skin over the clavicle. **NEET-PG High-Yield Pearls:** * **Erb’s Point (Neck):** The site where four cutaneous nerves emerge: Lesser occipital, Greater auricular, Transverse cervical, and Supraclavicular nerves. * **Nerve Block:** The posterior border of the SCM is the landmark for a **Cervical Plexus Block**, used for carotid endarterectomies. * **Referred Pain:** Pain from the diaphragm (phrenic nerve, C3-C5) is often referred to the shoulder tip because the **supraclavicular nerves** share the same spinal segments (C3, C4).

Question 1

A 67-year-old female presents with severe neck swelling. An MRI reveals an abscess in the middle of the posterior cervical triangle of the right side, which is surgically removed. Postoperatively, she experiences shoulder drooping and difficulty raising her right hand above her head. Which nerve has most likely been iatrogenically injured?

Accepted Answer

Accessory

Answer

Ansa cervicalis

Answer

Facial

Answer

Hypoglossal

Question 2

What is the correct description of the vertebral artery?

Accepted Answer

Passes through the C6 foramen transversarium.

Answer

Arises from the first part of the subclavian artery, posterior to the scalenus anterior.

Answer

Lies posterior to the inferior thyroid artery.

Answer

Passes posterior to the lateral mass of the atlas and then enters the foramen magnum.

Question 3

Which of the following statements is NOT true about the superior laryngeal nerve?

Accepted Answer

It supplies the larynx below the vocal cords.

Answer

Its block anesthetizes the laryngeal mucosa.

Answer

It passes through the thyrohyoid membrane.

Answer

It passes between the thyroid cartilage and the hyoid bone.

Question 4

A patient developed recurrent laryngeal nerve palsy during thyroid surgery. Which of the following laryngeal muscles is/are affected?

Accepted Answer

All

Answer

Posterior cricoarytenoid

Answer

Lateral cricoarytenoid

Answer

Thyroarytenoid

Question 5

Infection spreading via lymphatics from the lower lip first enters the blood stream at which location?

Accepted Answer

Brachiocephalic vein

Answer

Inferior labial vein

Answer

Inferior labial artery

Answer

Pterygoid venous plexus

Question 6

Where is the carotid sinus located?

Accepted Answer

Both at the termination of the common carotid artery and at the beginning of the internal carotid artery

Answer

At the termination of the common carotid artery

Answer

Behind the bifurcation of the common carotid artery

Answer

At the beginning of the internal carotid artery

Question 7

Which of the following is NOT an elastic laryngeal cartilage?

Accepted Answer

Thyroid

Answer

Epiglottis

Answer

Corniculate

Answer

Cuneiform

Question 8

A 38-year-old man has had thyroid surgery to remove his papillary carcinoma. The external laryngeal nerve, which accompanies the superior thyroid artery, is damaged during the surgery. This injury could result in a severe impairment of function of which of the following?

Accepted Answer

Tensing the vocal cords

Answer

Relaxing the vocal cords

Answer

Rotating the arytenoid cartilages

Answer

Widening the rima glottidis

Question 9

Pain referred to the right side of the neck extending laterally from the right clavicle to the tip of the right shoulder is most likely to involve which of the following?

Accepted Answer

Right phrenic nerve

Answer

Cervical cardiac accelerator nerves

Answer

Posterior vagal trunk

Answer

Right intercostal nerves

Question 10

A person receives a shallow knife wound just behind the sternocleidomastoid muscle and about 1 1/2 inches above the clavicle. There is an immediate numbness of the skin below the wound and over the acromion and clavicle. Which nerve is most likely severed?

Accepted Answer

Supraclavicular nerve

Answer

Greater auricular nerve

Answer

Lesser occipital nerve

Answer

Suprascapular nerve

Neck — MCQs

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