Neck — MCQs

A 56-year-old woman presents with a 7-month history of an enlarging lump on the right side of her neck. Physical examination reveals a 3-cm nodule in the right upper neck, medial to the sternocleidomastoid muscle and lateral to the trachea, at the angle of the mandible. A CT scan shows a circumscribed, solid mass adjacent to the carotid bifurcation. Microscopic examination of the excised mass reveals nests of round cells with pink, granular cytoplasm. Immunohistochemical markers chromogranin and S-100 are positive. Electron microscopy shows neurosecretory granules in the tumor cell cytoplasm. The tumor recurs 1 year later and is re-excised. What is the most likely diagnosis?

Q27Easy

What is the most common site of the internal opening of a branchial fistula?

Q28Medium

Which of the following statements is true about the atlanto-axial joint?

Q29Easy

Laryngocele arises from herniation through which membrane?

Q30Easy

Which muscle is supplied by the ansa cervicalis?

Neck Indian Medical PG Practice Questions and MCQs

Question 21: All of the following are midline swellings in the neck, except?

A. Branchial cyst (Correct Answer)
B. Sublingual dermoid cyst
C. Thyroglossal cyst
D. Subhyoid bursitis

Explanation: The correct answer is **Branchial cyst** because it is a **lateral** neck swelling, not a midline one. **1. Why Branchial Cyst is the correct answer:** A branchial cyst (specifically from the second branchial cleft, which accounts for 95% of cases) typically presents as a painless, fluctuant swelling located at the **junction of the upper 1/3rd and lower 2/3rd of the anterior border of the sternocleidomastoid muscle**. Because it arises from remnants of the branchial apparatus during embryogenesis, its anatomical position is always lateral to the midline. **2. Why the other options are incorrect (Midline Swellings):** * **Thyroglossal Cyst:** The most common midline developmental cyst. It occurs anywhere along the descent of the thyroglossal duct (from the foramen caecum to the thyroid isthmus). A classic sign is that it **moves upward on protrusion of the tongue**. * **Sublingual Dermoid Cyst:** These occur due to the entrapment of ectoderm during the fusion of the first branchial arches in the midline. They typically present in the submental region or the floor of the mouth. * **Subhyoid Bursitis:** This is an inflammation of the bursa located between the posterior surface of the hyoid bone and the thyrohyoid membrane. It presents as a smooth, transverse midline swelling just below the hyoid bone. **High-Yield Clinical Pearls for NEET-PG:** * **Midline Swellings:** Submental lymph nodes, Ranula (plunging), Thyroglossal cyst, Dermoid cyst, Isthmus of thyroid, and Pre-laryngeal/Pre-tracheal lymph nodes. * **Lateral Swellings:** Branchial cyst, Cystic hygroma [1] (usually in the posterior triangle), Carotid body tumor, and Cervical lymphadenopathy. * **Mnemonic for Thyroglossal Cyst:** "Moves with Deglutition (swallowing) AND Tongue protrusion." (Goiter only moves with deglutition).

Question 22: A patient presents with enlarged cervical lymph nodes and a malignant tumor of the cecum. Which of the following lymph nodes of the neck is most frequently associated with malignant tumors of the gastrointestinal tract?

A. Left inferior deep cervical lymph node
B. Left supraclavicular lymph node (Correct Answer)
C. Right inferior deep cervical lymph node
D. Right supraclavicular lymph node

Explanation: ### Explanation **Correct Answer: B. Left supraclavicular lymph node** The correct answer is the **Left supraclavicular lymph node**, also known as **Virchow’s node**. The underlying anatomical concept is the drainage pattern of the **thoracic duct**. The thoracic duct collects lymph from the entire body below the diaphragm (including the gastrointestinal tract, such as the cecum) and the left half of the body above the diaphragm [2]. It ascends through the thorax and typically empties into the junction of the left internal jugular and subclavian veins. When a malignancy occurs in the abdominal organs (stomach, colon, gallbladder, etc.), cancer cells can spread via the thoracic duct [2]. The left supraclavicular nodes are located near the termination of this duct; therefore, they are often the first site of palpable metastasis. The clinical finding of an enlarged, hard, painless left supraclavicular node is known as **Troisier’s sign**. **Why other options are incorrect:** * **A & C (Deep cervical nodes):** While these nodes receive drainage from the head and neck structures, they are not the primary site for systemic lymphatic drainage from the abdomen [1]. * **D (Right supraclavicular node):** This node receives drainage from the **right lymphatic duct**, which drains the right upper limb, the right side of the thorax, and the right side of the head and neck. It is more commonly associated with malignancies of the lung or esophagus rather than the lower GI tract. **High-Yield NEET-PG Pearls:** * **Virchow’s Node:** Specifically refers to the left supraclavicular node. * **Troisier’s Sign:** The clinical presence of Virchow’s node indicating occult abdominal malignancy (most commonly Gastric Adenocarcinoma). * **Sister Mary Joseph’s Nodule:** Periumbilical lymphadenopathy associated with abdominal/pelvic malignancy. * **Irish’s Node:** Left anterior axillary node enlargement associated with gastric cancer.

Question 23: Which of the following does NOT supply blood to the palatine tonsil?

A. Lingual artery
B. Facial artery
C. Ascending pharyngeal artery
D. Sphenopalatine artery (Correct Answer)

Explanation: The palatine tonsil is a highly vascular lymphoid tissue located in the tonsillar fossa. Its blood supply is derived from branches of the **External Carotid Artery (ECA)**. ### **Why Sphenopalatine Artery is the Correct Answer** The **Sphenopalatine artery** is the terminal branch of the maxillary artery. It enters the nasal cavity through the sphenopalatine foramen to supply the nasal septum and turbinates. It does **not** descend low enough to contribute to the tonsillar blood supply. ### **Analysis of Other Options (The Arterial Supply)** The palatine tonsil receives blood from five main sources: 1. **Facial Artery (Option B):** Provides the **Tonsillar branch**, which is the **main/principal artery** of the tonsil. It also contributes via the Ascending palatine artery. 2. **Lingual Artery (Option A):** Supplies the tonsil through its **Dorsal lingual branches**. 3. **Ascending Pharyngeal Artery (Option C):** A direct branch of the ECA that supplies the superior pole. 4. **Maxillary Artery:** Supplies the tonsil via the **Descending palatine artery** (Greater palatine branch). ### **High-Yield Clinical Pearls for NEET-PG** * **Principal Artery:** The tonsillar branch of the **Facial Artery** is the most significant source of bleeding during surgery. * **Venous Drainage:** The **Paratonsillar vein** (external palatine vein) is the most common cause of primary hemorrhage following a tonsillectomy. * **Nerve Supply:** The **Glossopharyngeal nerve (CN IX)** provides sensory innervation. Referred otalgia (ear pain) during tonsillitis occurs because CN IX also supplies the middle ear via Jacobson’s nerve. * **Lymphatics:** The tonsils drain into the **Jugulodigastric node**, often referred to as the "Tonsillar lymph node."

Question 24: The carotid sheath contains all the following structures EXCEPT:

A. Vagus nerve
B. Internal carotid artery
C. Phrenic nerve (Correct Answer)
D. Deep cervical lymph nodes

Explanation: The **carotid sheath** is a condensation of deep cervical fascia that extends from the base of the skull to the arch of the aorta. Understanding its contents is a high-yield topic for NEET-PG. ### Why Phrenic Nerve is the Correct Answer The **phrenic nerve** is not a content of the carotid sheath. It lies **posterior** to the sheath, embedded in the prevertebral fascia as it descends on the anterior surface of the scalenus anterior muscle [1]. While it is anatomically close, it remains outside the fascial compartment of the sheath. ### Analysis of Other Options * **Vagus Nerve (CN X):** This is a primary content, situated posteriorly in the groove between the artery and the vein [1]. * **Internal Carotid Artery (ICA):** The sheath contains the Common Carotid Artery (CCA) inferiorly and the ICA superiorly. Note: The External Carotid Artery (ECA) is **not** inside the sheath (except for its origin). * **Deep Cervical Lymph Nodes:** These are embedded within the connective tissue of the sheath, primarily along the internal jugular vein. ### NEET-PG High-Yield Pearls 1. **Mnemonic (VAN):** From medial to lateral, the contents are **V**agus nerve (posterior), **A**rtery (Common/Internal Carotid), and **N**erve (Internal Jugular Vein). 2. **Ansa Cervicalis:** The anterior wall of the carotid sheath contains the superior belly of the ansa cervicalis. 3. **Sympathetic Chain:** Like the phrenic nerve, the sympathetic trunk is **not** a content; it lies posterior to the sheath, embedded in prevertebral fascia. 4. **Clinical Significance:** The carotid sheath serves as a conduit for the spread of infections from the head and neck into the mediastinum.

Question 25: A 33-year-old male patient complains of severe pain when he tries to turn his neck. The physician realizes that the problem is in his pivot (trochoid) joint. Which of the following joints would most likely be examined?

A. Atlantooccipital joint
B. Atlantoaxial joint (Correct Answer)
C. Carpometacarpal joint
D. Proximal tibiofibular joint

Explanation: ### Explanation **Correct Answer: B. Atlantoaxial joint** The **atlantoaxial joint** is a classic example of a **pivot (trochoid) joint**. It consists of the articulation between the dens (odontoid process) of the axis (C2) and the anterior arch of the atlas (C1). In a pivot joint, a rounded process of bone rotates within a ring formed by another bone and a ligament. This specific joint is responsible for the rotation of the head (the "no" movement), which aligns with the patient's clinical presentation of pain when turning the neck. **Analysis of Incorrect Options:** * **A. Atlantooccipital joint:** This is a **condyloid (ellipsoid) joint** between the occipital condyles and the atlas. It primarily allows for flexion and extension (the "yes" movement), not rotation. * **C. Carpometacarpal joint:** The 1st CMC joint (thumb) is a **saddle (sellar) joint**. Other CMC joints are typically plane synovial joints. * **D. Proximal tibiofibular joint:** This is a **plane (gliding) synovial joint** that allows for slight movement during ankle dorsiflexion. **High-Yield Clinical Pearls for NEET-PG:** * **Pivot Joints in the Body:** There are only two primary examples: the **Median Atlantoaxial joint** and the **Radio-ulnar joints** (proximal and distal). * **Ligamentous Support:** The **transverse ligament of the atlas** is crucial for stabilizing the atlantoaxial joint; its rupture (e.g., in Rheumatoid Arthritis or Down Syndrome) can lead to atlantoaxial subluxation and spinal cord compression. * **Movement Mnemonic:** **A**tlanto-**O**ccipital = **O**K (Nodding/Yes); **A**tlanto-**A**xial = **O**round (Rotation/No).

Question 26: A 56-year-old woman presents with a 7-month history of an enlarging lump on the right side of her neck. Physical examination reveals a 3-cm nodule in the right upper neck, medial to the sternocleidomastoid muscle and lateral to the trachea, at the angle of the mandible. A CT scan shows a circumscribed, solid mass adjacent to the carotid bifurcation. Microscopic examination of the excised mass reveals nests of round cells with pink, granular cytoplasm. Immunohistochemical markers chromogranin and S-100 are positive. Electron microscopy shows neurosecretory granules in the tumor cell cytoplasm. The tumor recurs 1 year later and is re-excised. What is the most likely diagnosis?

A. Metastatic squamous cell carcinoma
B. Metastatic thyroid medullary carcinoma
C. Mucoepidermoid carcinoma
D. Paraganglioma (Correct Answer)

Explanation: The clinical presentation and histopathology point definitively to a **Paraganglioma**, specifically a **Carotid Body Tumor**. [3] **Why the correct answer is right:** 1. **Anatomical Location:** The mass is located at the **carotid bifurcation** (angle of the mandible), which is the classic site for a carotid body tumor. [3] 2. **Histopathology:** The "nests of round cells" describe the characteristic **Zellballen pattern** (nests of chief cells surrounded by sustentacular cells). [2] 3. **Immunohistochemistry (IHC):** **Chromogranin** positivity confirms the neuroendocrine nature of the chief cells, while **S-100** positivity highlights the peripheral sustentacular cells. 4. **Electron Microscopy:** The presence of **neurosecretory granules** is a hallmark of amine precursor uptake and decarboxylation (APUD) cells found in paragangliomas. **Why incorrect options are wrong:** * **Metastatic Squamous Cell Carcinoma:** While common in the neck, it would show keratin pearls or intercellular bridges on microscopy and would be negative for chromogranin/S-100. [3] * **Metastatic Thyroid Medullary Carcinoma:** Although it is a neuroendocrine tumor (positive for chromogranin), it typically presents with amyloid stroma and is located within the thyroid or along lymphatic chains, not specifically at the carotid bifurcation. [1] * **Mucoepidermoid Carcinoma:** This is a salivary gland tumor. It would show a mixture of squamous, mucous, and intermediate cells, lacking neurosecretory granules. [3] **High-Yield Pearls for NEET-PG:** * **Lyre Sign:** On angiography, a carotid body tumor characteristically splayed the internal and external carotid arteries. * **Fontaine’s Sign:** The mass is mobile horizontally but fixed vertically (due to its attachment to the carotid bifurcation). * **Rule of 10s:** Approximately 10% are familial (associated with SDH mutations), 10% are bilateral, and 10% are malignant. * **Origin:** Derived from **neural crest cells**.

Question 27: What is the most common site of the internal opening of a branchial fistula?

A. Lateral nasopharyngeal wall
B. Fossa of Rosenmuller
C. Gingivolabial sulcus
D. Tonsillar fossa (Correct Answer)

Explanation: ### Explanation The correct answer is **D. Tonsillar fossa**. **1. Why the Correct Answer is Right:** Branchial fistulae are congenital anomalies resulting from the failure of the branchial clefts and pouches to obliterate during embryonic development [1]. The **second branchial arch** is the most common source of branchial anomalies (approx. 95%). * A **second branchial fistula** typically has an external opening along the lower third of the anterior border of the sternocleidomastoid muscle. * The tract travels upwards, passing between the internal and external carotid arteries (bifurcation), and terminates at an **internal opening** located in the **tonsillar fossa** (specifically on the posterior pillar or the supratonsillar fossa) [1]. This is because the second branchial pouch gives rise to the palatine tonsil. **2. Why the Incorrect Options are Wrong:** * **A & B (Lateral nasopharyngeal wall / Fossa of Rosenmuller):** These sites are associated with the **first branchial pouch** (which forms the Eustachian tube and middle ear) [1]. Anomalies of the first branchial cleft usually open into the external auditory canal or the submandibular region, not the tonsillar fossa. * **C (Gingivolabial sulcus):** This is not a standard site for branchial pouch derivatives. It is more commonly associated with odontogenic cysts or minor salivary gland pathology. **3. High-Yield Clinical Pearls for NEET-PG:** * **Course of the 2nd Branchial Fistula:** It always passes **above** the glossopharyngeal nerve (CN IX) and **below** the hypoglossal nerve (CN XII). * **3rd Branchial Fistula:** Rare; the internal opening is in the **pyriform fossa** (above the superior laryngeal nerve). * **4th Branchial Fistula:** Extremely rare; it loops around the subclavian artery (right) or aorta (left) and opens into the **apex of the pyriform fossa** (below the superior laryngeal nerve). * **Rule of Thumb:** The number of the pouch corresponds to the adult structure it forms (e.g., 2nd pouch = Tonsil; 3rd pouch = Inferior parathyroid/Thymus).

Question 28: Which of the following statements is true about the atlanto-axial joint?

A. The vertebral artery passes posterior to the foramen magnum.
B. The atlanto-occipital joint permits flexion and extension movements. (Correct Answer)
C. The posterior longitudinal ligament does not pass through the spinal canal.
D. The atlanto-axial joint is an ellipsoid joint.

Explanation: The **atlanto-occipital joint** is a synovial joint of the ellipsoid variety formed between the superior articular facets of the atlas (C1) and the occipital condyles. Its primary function is to permit **flexion and extension** (the "nodding" or "Yes" movement), along with slight lateral flexion. ### Analysis of Options: * **Option B (Correct):** The atlanto-occipital joint acts as a hinge-like ellipsoid joint, primarily facilitating the nodding motion of the head. * **Option A (Incorrect):** The vertebral artery enters the skull through the **foramen magnum**, not posterior to it. It travels through the transverse foramina of C6–C1, winds behind the lateral mass of the atlas, and pierces the posterior atlanto-occipital membrane to enter the cranial cavity. * **Option C (Incorrect):** The **Posterior Longitudinal Ligament (PLL)** runs along the posterior surface of the vertebral bodies *inside* the spinal canal. Its superior continuation (from C2 to the internal surface of the occipital bone) is known as the **Membrana Tectoria**. * **Option D (Incorrect):** The atlanto-axial joint is a complex joint consisting of two lateral plane joints and one median **pivot joint** (between the dens of C2 and the anterior arch of C1). It facilitates rotation (the "No" movement). ### High-Yield NEET-PG Pearls: * **"Yes" Joint:** Atlanto-occipital (Ellipsoid; Flexion/Extension). * **"No" Joint:** Atlanto-axial (Pivot; Rotation). * **Cruciate Ligament:** Essential for stabilizing the dens; the **transverse ligament of the atlas** is its strongest component. * **Steel’s Rule of Thirds:** At the level of the atlas, the spinal canal is occupied by 1/3rd dens, 1/3rd spinal cord, and 1/3rd "safe space" (fluid and fat).

Question 29: Laryngocele arises from herniation through which membrane?

A. Thyroid membrane
B. Cricoepiglottic membrane
C. Thyrohyoid membrane (Correct Answer)
D. Cricovocal membrane

Explanation: **Explanation:** A **laryngocele** is an abnormal cystic expansion or herniation of the **saccule of the laryngeal ventricle**. The saccule is a blind pouch extending upward from the anterior part of the ventricle between the vestibular fold and the thyroid cartilage. 1. **Why Thyrohyoid Membrane is correct:** The saccule contains mucous glands. When the saccule becomes distended with air (often due to increased intra-laryngeal pressure, as seen in trumpet players or glassblowers), it can protrude superiorly. An **external laryngocele** specifically pierces the **thyrohyoid membrane** at the point where the superior laryngeal artery and the internal laryngeal nerve enter the larynx. It then presents as a reducible swelling in the neck that enlarges with the Valsalva maneuver. 2. **Why other options are incorrect:** * **Thyroid membrane:** This is a non-standard anatomical term; the relevant structure is the thyrohyoid membrane. * **Cricoepiglottic membrane:** This refers to the quadrangular membrane. While the saccule lies lateral to it, the herniation does not occur through this membrane to reach the neck. * **Cricovocal membrane (Conus Elasticus):** This membrane forms the lower part of the intrinsic laryngeal membranes (leading to the vocal cords). Herniation here would not result in a laryngocele. **Clinical Pearls for NEET-PG:** * **Internal Laryngocele:** Remains within the larynx, causing hoarseness or airway obstruction. * **External Laryngocele:** Pierces the thyrohyoid membrane; presents as a neck mass. * **Bryce’s Sign:** A gurgling sound heard on compression of the swelling (pathognomonic for laryngocele). * **Association:** In adults, always rule out **Squamous Cell Carcinoma** of the larynx obstructing the ventricular orifice.

Question 30: Which muscle is supplied by the ansa cervicalis?

A. Sternohyoid (Correct Answer)
B. Mylohyoid
C. Cricothyroid
D. Stylohyoid

Explanation: **Explanation:** The **Ansa Cervicalis** is a loop of nerves from the cervical plexus (C1–C3) located in the carotid triangle. It is responsible for supplying the **infrahyoid muscles** (also known as "strap muscles"), which function to depress the hyoid bone and larynx. **Why Sternohyoid is Correct:** The ansa cervicalis supplies three out of the four infrahyoid muscles: the **Sternohyoid**, **Sternothyroid**, and **Omohyoid**. The superior belly of the omohyoid is supplied by the superior root (C1), while the inferior belly, sternohyoid, and sternothyroid are supplied by the inferior root/loop (C2–C3). Note: The fourth infrahyoid muscle, the *Thyrohyoid*, is supplied by C1 fibers traveling via the Hypoglossal nerve. **Why the other options are incorrect:** * **Mylohyoid (B):** This is a suprahyoid muscle supplied by the **Nerve to Mylohyoid**, a branch of the mandibular nerve (V3). * **Cricothyroid (C):** This is an intrinsic muscle of the larynx supplied by the **External Laryngeal Nerve** (a branch of the Vagus nerve). * **Stylohyoid (D):** This is a suprahyoid muscle supplied by the **Facial Nerve (CN VII)**. **High-Yield Facts for NEET-PG:** 1. **The C1 Exception:** Fibers from C1 supply both the **Thyrohyoid** and the **Geniohyoid** muscles, but they reach these muscles by "hitching a ride" with the Hypoglossal nerve (CN XII). 2. **Surgical Landmark:** The ansa cervicalis is usually found embedded in the anterior wall of the **carotid sheath**, overlying the internal jugular vein. 3. **Mnemonic:** To remember the muscles supplied by the ansa cervicalis, think **"SOS"** (Sternohyoid, Omohyoid, Sternothyroid).

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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

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Cervical Plexus

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Root of the Neck

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Applied Anatomy and Clinical Correlations

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