Neck — MCQs

A 45-year-old woman presents with neck pain. A CT scan reveals a tumor in the left side of her oral cavity. Following a radical neck surgical procedure for tumor removal, the patient's left shoulder droops noticeably two months postoperatively. Physical examination reveals distinct weakness in turning her head to the right and impairment of abduction of her left upper limb to the level of the shoulder. Which of the following structures was most likely injured during the radical neck surgery?

Q218Easy

Which muscle is supplied by the external branch of the superior laryngeal nerve?

Q219Easy

Into which lymph node do the lymphatics of the tonsils primarily drain?

Q220Medium

Which of the following statements regarding the parathyroid glands is INCORRECT?

Neck Indian Medical PG Practice Questions and MCQs

Question 211: Which nerve supplies the vocal cords?

A. External laryngeal nerve
B. Internal laryngeal nerve
C. Recurrent laryngeal nerve (Correct Answer)
D. Vagus nerve

Explanation: The nerve supply to the larynx is a high-yield topic for NEET-PG, primarily derived from the **Vagus nerve (CN X)** via its laryngeal branches. [1] ### **Explanation of the Correct Answer** The **Recurrent Laryngeal Nerve (RLN)** is the correct answer because it provides: 1. **Motor supply:** To all intrinsic muscles of the larynx **except** the cricothyroid. This includes the muscles that move the vocal cords (abductors, adductors, and relaxors). 2. **Sensory supply:** To the laryngeal mucosa **below** the level of the vocal cords. Since the RLN controls the muscles that manipulate the vocal cords (specifically the *posterior cricoarytenoid* for abduction and *lateral cricoarytenoid* for adduction), it is the functional nerve of the vocal cords. [1] ### **Why Other Options are Incorrect** * **External Laryngeal Nerve:** It supplies only the **cricothyroid muscle** (the "tenser" of the vocal cords). While it affects the pitch of the voice, it does not supply the vocal cords' primary intrinsic musculature or mucosa. * **Internal Laryngeal Nerve:** It is purely **sensory**. It supplies the laryngeal mucosa **above** the vocal cords (up to the epiglottis) and is responsible for the cough reflex. * **Vagus Nerve:** While the RLN is a branch of the Vagus, the question asks for the specific nerve. In anatomy exams, always choose the most distal/specific branch. ### **High-Yield Clinical Pearls** * **Unilateral RLN injury:** Results in hoarseness of voice as the vocal cord assumes a paramedian position. * **Bilateral RLN injury:** Can lead to inspiratory stridor and dyspnea because the vocal cords cannot abduct (open). * **Semon’s Law:** In progressive lesions of the RLN, abductor muscles (posterior cricoarytenoid) are paralyzed before adductor muscles. * **Surgery Link:** The RLN is most commonly injured during **Thyroidectomy** due to its close proximity to the inferior thyroid artery. [1]

Question 212: Which of the following statements is FALSE regarding the anterior triangle of the neck?

A. Its posterior boundary is the anterior border of the Sternocleidomastoid muscle.
B. It is a part of the anterior triangle of the neck.
C. Its superior boundary is the anterior belly of the digastric muscle. (Correct Answer)
D. Its anteroinferior boundary is the superior belly of the Omohyoid muscle.

Explanation: This question tests your knowledge of the boundaries of the **Carotid Triangle**, which is a high-yield subdivision of the anterior triangle of the neck. ### **Explanation of the Correct Answer (Option C)** Option C is the **FALSE** statement because the **superior boundary** of the carotid triangle is formed by the **posterior belly of the digastric muscle** (along with the stylohyoid), not the anterior belly. The anterior belly of the digastric muscle forms the lateral boundary of the submental triangle and the anterior boundary of the digastric (submandibular) triangle. ### **Analysis of Other Options** * **Option A:** Correct. The **posterior boundary** of the entire anterior triangle (and specifically the carotid triangle) is the **anterior border of the Sternocleidomastoid (SCM)**. * **Option B:** Correct. The carotid triangle is one of the four subdivisions of the anterior triangle (the others being the submental, submandibular, and muscular triangles). * **Option C:** Correct. The **anteroinferior boundary** is formed by the **superior belly of the omohyoid muscle**. ### **High-Yield NEET-PG Clinical Pearls** * **Contents of the Carotid Triangle:** It contains the Carotid sheath (Common Carotid artery, Internal Jugular Vein, and Vagus nerve), the bifurcation of the CCA, and the **Ansa Cervicalis** (embedded in the anterior wall of the sheath). * **Carotid Sinus vs. Body:** The Carotid **Sinus** (at the bifurcation) acts as a **baroreceptor** (pressure), while the Carotid **Body** acts as a **chemoreceptor** (O2/CO2 levels). Both are innervated primarily by the **Glossopharyngeal nerve (CN IX)**. * **Surgical Landmark:** The carotid triangle is the preferred site for carotid endarterectomy and for palpating the carotid pulse.

Question 213: Which of the following is the most common location of a branchial cyst?

A. Upper third of the anterior border of the sternocleidomastoid muscle (Correct Answer)
B. Upper third of the posterior border of the sternocleidomastoid muscle
C. Lower third of the posterior border of the sternocleidomastoid muscle
D. Lower third of the anterior border of the sternocleidomastoid muscle

Explanation: The correct answer is **A: Upper third of the anterior border of the sternocleidomastoid muscle.** **1. Underlying Medical Concept:** Branchial cysts are congenital epithelial cysts that arise due to the failure of the **second branchial cleft** to involute during embryonic development. This results in a persistent cervical sinus of His. Anatomically, the second branchial cleft remnants are located along the **anterior border of the sternocleidomastoid (SCM) muscle**, specifically at the junction of its **upper and middle thirds** [2]. They are typically found deep to the deep cervical fascia and superficial to the carotid sheath, often just below the angle of the mandible. **2. Analysis of Incorrect Options:** * **B & C (Posterior border of SCM):** The posterior triangle of the neck is the site for cystic hygromas or lymphadenopathy [1]. Branchial remnants are associated with the anterior triangle. * **D (Lower third of anterior border):** While branchial *fistulae* (which are congenital and present at birth) often have an external opening in the lower third of the neck, branchial *cysts* (which typically present in late adolescence or early adulthood) are most commonly found in the upper third. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Type:** 95% of branchial anomalies arise from the **second branchial cleft** [2]. * **Clinical Presentation:** A smooth, non-tender, fluctuant swelling that may enlarge during upper respiratory tract infections. * **Pathology:** Usually lined by stratified squamous epithelium and contains "straw-colored" fluid with **cholesterol crystals**. * **Differential Diagnosis:** Must be distinguished from a Carotid Body Tumor (which is pulsatile and has a "Lyre sign" on imaging). * **Surgical Note:** The tract of a second branchial fistula passes between the internal and external carotid arteries and opens into the **tonsillar fossa** [2].

Question 214: All of the following are spaces related to the larynx except:

A. Space of Boyer
B. Space of Tucker
C. Reinke's space
D. Space of Gillette (Correct Answer)

Explanation: The correct answer is **Space of Gillette** because it is a retropharyngeal space, not an intralaryngeal one. ### **Explanation of Options** * **Space of Gillette (Correct Answer):** This is a potential space located in the **retropharyngeal region**, specifically between the buccopharyngeal fascia and the prevertebral fascia. It contains the Nodes of Rouviere (lateral retropharyngeal nodes). Infections here can lead to retropharyngeal abscesses, which may bulge into the posterior pharyngeal wall. * **Space of Boyer (Incorrect):** This is the **pre-epiglottic space**. It is a wedge-shaped, fat-filled space located anterior to the epiglottis and posterior to the thyrohyoid membrane. It is clinically significant because it allows for the silent horizontal spread of supraglottic tumors. * **Space of Tucker (Incorrect):** This is the **paraglottic space**. It is a potential space lateral to the laryngeal ventricles, bounded by the thyroid cartilage laterally and the conus elasticus medially. It is a key pathway for the vertical spread of transglottic tumors. * **Reinke’s Space (Incorrect):** This is a subepithelial potential space of the **vocal folds** (between the epithelium and the vocal ligament). Accumulation of fluid here leads to "Reinke’s edema," commonly seen in chronic smokers. ### **High-Yield Clinical Pearls for NEET-PG** * **Pre-epiglottic space (Boyer)** involvement is a primary reason for performing a total laryngectomy in supraglottic cancers. * **Paraglottic space (Tucker)** involvement often results in vocal cord fixation. * **Retropharyngeal space (Gillette)** infections are most common in children due to the presence of the Nodes of Rouviere, which atrophy after age 4–5.

Question 215: The thyroidea ima artery is not a branch of which of the following?

A. Brachiocephalic trunk
B. Subclavian artery
C. Vertebral artery (Correct Answer)
D. Arch of aorta

Explanation: ### Explanation The **thyroidea ima artery** is an anatomical variant present in approximately **3–10% of the population**. It is an accessory artery that supplies the thyroid gland, typically compensating for the absence or small size of the inferior thyroid arteries. **Why Vertebral Artery is the Correct Answer:** The thyroidea ima artery typically arises from midline or near-midline structures within the superior mediastinum or the root of the neck. The **vertebral artery** is a branch of the first part of the subclavian artery that ascends through the foramina transversaria of the cervical vertebrae. It is located too far laterally and posteriorly to give rise to the thyroidea ima, which must ascend anterior to the trachea to reach the thyroid isthmus. **Analysis of Other Options:** * **Brachiocephalic trunk (Innominate artery):** This is the **most common source** of the thyroidea ima artery. * **Arch of aorta:** The artery can arise directly from the arch, usually between the brachiocephalic trunk and the left common carotid. * **Subclavian artery:** It may occasionally arise from the right subclavian artery or the internal thoracic artery [1]. **High-Yield Clinical Pearls for NEET-PG:** 1. **Course:** It ascends on the **anterior surface of the trachea** to reach the lower border of the **thyroid isthmus**. 2. **Surgical Significance:** It is a major "danger" structure during emergency **tracheostomy** or thyroidectomy [1]. Accidental injury can lead to profuse hemorrhage that may retract into the mediastinum. 3. **Supply:** It primarily supplies the thyroid gland but can also give branches to the thymus (as the *thymica accessoria*). 4. **Embryology:** It represents a persistent developmental vessel from the aortic arches that failed to regress.

Question 216: When a large bolus of food is swallowed, the hyoid bone moves anteriorly to open the pharynx. The muscle responsible for this action is innervated by which of the following nerves?

A. C1 (ansa cervicalis) (Correct Answer)
B. Cranial Nerve IX
C. Pharyngeal plexus
D. Cranial Nerve V3

Explanation: **Explanation:** The muscle responsible for the anterior movement of the hyoid bone (and consequently the larynx) to open the pharynx during swallowing is the **Geniohyoid**. 1. **Why A is correct:** The geniohyoid muscle originates from the inferior mental spine of the mandible and inserts into the hyoid bone. When it contracts, it pulls the hyoid bone anterosuperiorly, widening the pharynx to accommodate a food bolus. It is innervated by the **C1 nerve fibers** traveling via the **Hypoglossal nerve (CN XII)**. While it is technically "C1 via XII," in the context of NEET-PG, it is categorized under the C1/Ansa cervicalis complex. 2. **Why the others are wrong:** * **CN IX (Glossopharyngeal):** Innervates the Stylopharyngeus. While this muscle elevates the pharynx, it does not primarily drive the anterior displacement of the hyoid. * **Pharyngeal Plexus:** Formed by CN IX, X, and sympathetic fibers. It innervates most pharyngeal constrictors and palatal muscles (except Tensor Veli Palatini and Stylopharyngeus), which are involved in peristalsis, not anterior hyoid displacement. * **CN V3 (Mandibular nerve):** Innervates the Mylohyoid and the anterior belly of the digastric. While these elevate the hyoid, the specific "anterior" pull for pharyngeal opening is the hallmark of the Geniohyoid. **High-Yield NEET-PG Pearls:** * **C1 via CN XII:** Supplies two muscles—the **Geniohyoid** and the **Thyrohyoid**. * **Ansa Cervicalis (C1-C3):** Supplies the "SOS" muscles—**S**ternohyoid, **O**mohyoid, and **S**ternothyroid. * **Deglutition Tip:** The elevation and anterior displacement of the larynx under the tongue base is essential to protect the airway and open the esophagus.

Question 217: A 45-year-old woman presents with neck pain. A CT scan reveals a tumor in the left side of her oral cavity. Following a radical neck surgical procedure for tumor removal, the patient's left shoulder droops noticeably two months postoperatively. Physical examination reveals distinct weakness in turning her head to the right and impairment of abduction of her left upper limb to the level of the shoulder. Which of the following structures was most likely injured during the radical neck surgery?

A. Suprascapular nerve
B. Long thoracic nerve
C. Spinal accessory nerve (Correct Answer)
D. The junction of spinal nerves C5 and C6 of the brachial plexus

Explanation: ### Explanation **1. Why the Spinal Accessory Nerve (CN XI) is correct:** The clinical presentation of **shoulder drooping** and **weakness in head rotation** is a classic sign of Spinal Accessory Nerve injury. * **Trapezius muscle:** CN XI provides motor innervation to the trapezius. Paralysis leads to drooping of the shoulder and an inability to abduct the arm above 90 degrees (as the trapezius is essential for upward rotation of the scapula). * **Sternocleidomastoid (SCM) muscle:** CN XI also innervates the SCM. Since the left SCM rotates the head to the *right*, an injury to the left nerve results in weakness when turning the head to the opposite side. * **Surgical Context:** The Spinal Accessory Nerve is highly vulnerable during radical neck dissections as it crosses the posterior triangle of the neck. **2. Why the other options are incorrect:** * **A. Suprascapular nerve:** Innervates the supraspinatus (initiates abduction) and infraspinatus. While injury affects abduction, it would not cause SCM weakness or shoulder drooping. * **B. Long thoracic nerve:** Innervates the serratus anterior. Injury causes "winging of the scapula," not a drooping shoulder or SCM deficit. * **D. Junction of C5-C6 (Erb’s Point):** Injury here (Erb’s Palsy) leads to the "waiter’s tip" deformity. While it affects abduction, it involves multiple muscles (deltoid, biceps, brachialis) and would not explain the SCM weakness. **3. NEET-PG Clinical Pearls:** * **Surface Anatomy:** The Spinal Accessory Nerve emerges at the junction of the upper 1/3rd and lower 2/3rds of the posterior border of the SCM. * **The "Shrug" Test:** Clinical testing for CN XI involves shrugging the shoulders against resistance (Trapezius) and turning the chin against resistance (SCM). * **Iatrogenic Injury:** The most common cause of CN XI injury is iatrogenic, specifically during lymph node biopsies in the posterior triangle or radical neck surgeries.

Question 218: Which muscle is supplied by the external branch of the superior laryngeal nerve?

A. Cricothyroid (Correct Answer)
B. Thyroarytenoid
C. Posterior cricoarytenoid
D. Cricoarytenoid

Explanation: **Explanation:** The nerve supply of the laryngeal muscles follows a very specific "rule of thumb" in anatomy, which is a high-yield concept for NEET-PG. **1. Why Cricothyroid is correct:** The **External Laryngeal Nerve** (a branch of the Superior Laryngeal Nerve) provides motor innervation to only one muscle: the **Cricothyroid** [1]. This muscle acts as a tensor of the vocal cords by tilting the thyroid cartilage forward. It is the only laryngeal muscle located on the external surface of the larynx, which explains why it is supplied by the external branch. **2. Why the other options are incorrect:** * **Thyroarytenoid, Posterior cricoarytenoid, and Lateral cricoarytenoid:** All intrinsic muscles of the larynx (except the cricothyroid) are supplied by the **Recurrent Laryngeal Nerve (RLN)**. * The **Posterior cricoarytenoid** is particularly important as it is the only abductor of the vocal cords ("safety muscle of the larynx"). **Clinical Pearls for NEET-PG:** * **Nerve Injury:** Injury to the external laryngeal nerve (often during thyroidectomy when ligating the superior thyroid artery) results in the inability to create high-pitched sounds due to loss of cricothyroid function (the "monotone voice") [1]. * **Sensory Supply:** The **Internal Laryngeal Nerve** provides sensory innervation to the larynx *above* the vocal folds, while the **Recurrent Laryngeal Nerve** provides sensory innervation *below* the vocal folds. * **Surgical Landmark:** The external laryngeal nerve travels in close proximity to the **superior thyroid artery**, whereas the recurrent laryngeal nerve is closely related to the **inferior thyroid artery** [1].

Question 219: Into which lymph node do the lymphatics of the tonsils primarily drain?

A. Jugulodigastric lymph node (Correct Answer)
B. Jugulo-omohyoid lymph node
C. Submandibular lymph node
D. Submental lymph node

Explanation: The palatine tonsils are part of the Waldeyer’s ring and have a specific lymphatic drainage pattern that is frequently tested in NEET-PG. ### **Explanation of the Correct Answer** The **Jugulodigastric lymph node** (also known as the **Principal lymph node of the tonsil**) is the primary site for tonsillar drainage. It is located in the deep cervical chain, specifically where the posterior belly of the digastric muscle crosses the internal jugular vein. Because it is the first station to receive lymph from the palatine tonsils, it is the most common node to become enlarged and tender during acute tonsillitis. ### **Analysis of Incorrect Options** * **B. Jugulo-omohyoid lymph node:** This node is located where the omohyoid muscle crosses the internal jugular vein. It primarily receives drainage from the **tongue** (specifically the submental and submandibular nodes) and is not the primary station for the tonsils. * **C. Submandibular lymph node:** These nodes receive lymph from the front of the scalp, nose, cheeks, upper lip, and the lateral parts of the lower lip and tongue. * **D. Submental lymph node:** These nodes drain the tip of the tongue, the floor of the mouth, and the central part of the lower lip. ### **High-Yield Clinical Pearls for NEET-PG** * **Location:** The Jugulodigastric node belongs to the **Level II** cervical lymph nodes. * **Clinical Sign:** In clinical practice, a palpable, tender jugulodigastric node is a hallmark sign of **acute follicular tonsillitis**. * **Waldeyer’s Ring:** Remember that while the palatine tonsils drain to the jugulodigastric nodes, the pharyngeal tonsils (adenoids) drain primarily to the **retropharyngeal lymph nodes**.

Question 220: Which of the following statements regarding the parathyroid glands is INCORRECT?

A. The superior parathyroid gland develops from the third pharyngeal pouch. (Correct Answer)
B. The normal parathyroid gland weighs up to 50 mg.
C. The inferior parathyroid gland descends along with the thymus.
D. The superior parathyroid gland is more consistent in its position than the inferior gland.

Explanation: ### Explanation **1. Why Option A is the Correct (Incorrect) Statement:** The **superior parathyroid glands** (Parathyroid IV) develop from the **fourth pharyngeal pouch**, not the third. Conversely, the **inferior parathyroid glands** (Parathyroid III) develop from the **third pharyngeal pouch**. This is a classic "embryological flip" that occurs because the third pouch also gives rise to the thymus. **2. Analysis of Other Options:** * **Option B:** The average weight of a single normal parathyroid gland is approximately **30–50 mg**. Total weight of all four glands is usually less than 150 mg. * **Option C:** During development, the inferior parathyroid glands are attached to the **thymus** (both from the 3rd pouch). As the thymus migrates caudally into the mediastinum, it pulls the inferior parathyroid glands down with it. * **Option D:** Because the superior glands (4th pouch) have a shorter migratory path, they are **more constant in position**, usually located behind the middle of the posterior border of the thyroid lobe [1]. The inferior glands have a longer, more variable migration path, making them more likely to be found in ectopic locations (e.g., within the thymus or mediastinum) [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Blood Supply:** Both superior and inferior glands are primarily supplied by the **inferior thyroid artery** (an important landmark during thyroidectomy) [1]. * **Ectopic Locations:** If an inferior parathyroid gland is missing, it is most commonly found in the **superior mediastinum** within the thymus. * **Surgical Landmark:** The superior parathyroid gland is usually found **dorsal** to the recurrent laryngeal nerve, while the inferior gland is usually **ventral** to it [1].

Practice by Chapter

Cervical Fascia

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Triangles of the Neck

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Deep Structures of the Neck

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Thyroid and Parathyroid Glands

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Vasculature of the Neck

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Lymphatic Drainage

Practice Questions

Cervical Plexus

Practice Questions

Root of the Neck

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Applied Anatomy and Clinical Correlations

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Surface Anatomy of the Neck

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