Neck Spaces and Fasciae — MCQs

10 questions

Middle age diabetic with tooth extraction with ipsilateral swelling over middle one-third of sternocleidomastoid & displacement of tonsils towards contralateral -

A resident at the emergency department is preparing for a lumbar puncture in a 26 years old female with suspected subarachnoid bleeding. Although she presented with altered sensorium, CT brain was found to be normal. During LP, which structure is pierced after the spinal needle crosses interspinous ligament?

Which of the following structures is not found in the parotid gland?

You evaluate an 18 yrs old male who sustained a right sided cervical laceration during a gang fight. Which of the following is a relative rather than an absolute indication for neck exploration?

Cause of Ludwig angina is:

Which of the following statements about Sibson's fascia is correct?

Sitaram a 40-year old man, met with an accident and comes to emergency department with engorged neck veins, pallor, rapid pulse and chest pain Diagnosis is -

Which statement considering the relations of nerves to the humerus is the most accurate?

Q9Easy

Secondaries in the neck with no obvious primary malignancy is most often due to which of the following?

Q10Medium

What clinical appearance is associated with bilateral TMJ ankylosis?

Neck Spaces and Fasciae Indian Medical PG Practice Questions and MCQs

Question 1: Middle age diabetic with tooth extraction with ipsilateral swelling over middle one-third of sternocleidomastoid & displacement of tonsils towards contralateral -

A. Ludwigs angina
B. Parapharyngeal abscess (Correct Answer)
C. Retropharyngeal abscess
D. None of the options

Explanation: ***Parapharyngeal abscess*** - The **ipsilateral swelling** over the middle one-third of the sternocleidomastoid and **contralateral tonsil displacement** are classic signs of a parapharyngeal abscess, often secondary to an odontogenic infection. - This location involves the space lateral to the pharynx, which can expand and push structures like the tonsils medially. *Ludwig's angina* - Ludwig's angina is a **rapidly progressive cellulitis** of the submandibular, sublingual, and submental spaces, typically bilateral. - It presents with **brawny induration** of the neck and elevation of the tongue, but usually without a distinct mass displacing the tonsils. *Retropharyngeal abscess* - A retropharyngeal abscess develops in the space behind the posterior pharyngeal wall, usually presenting with **swelling of the posterior pharyngeal wall**. - It more commonly causes **dysphagia**, **stridor**, and neck stiffness, and does not typically result in significant ipsilateral external neck swelling or contralateral tonsil displacement like a parapharyngeal abscess. *None of the options* - The described clinical presentation, with a history of **tooth extraction**, ipsilateral sternocleidomastoid swelling, and contralateral tonsil displacement, is highly specific for a parapharyngeal abscess. - This option is incorrect because there is a clear and well-matched diagnosis among the choices.

Question 2: A resident at the emergency department is preparing for a lumbar puncture in a 26 years old female with suspected subarachnoid bleeding. Although she presented with altered sensorium, CT brain was found to be normal. During LP, which structure is pierced after the spinal needle crosses interspinous ligament?

A. Supra/inter spinous ligament
B. Skin
C. Sub cutaneous fascia
D. Dura mater
E. Arachnoid mater
F. Ligamentum flava (Correct Answer)

Explanation: The enriched explanation is the original text provided because none of the references were sufficiently relevant to the anatomy of a lumbar puncture. Ligamentum flava - After passing the interspinous ligament, the next significant structure pierced by the spinal needle during a lumbar puncture is the ligamentum flava. - This ligament is crucial for stabilizing the vertebral column and is located anterior to the interspinous ligament, connecting the laminae of adjacent vertebrae. *Supra/inter spinous ligament* - The question explicitly states that the needle has already crossed the interspinous ligament, making this an incorrect choice for the next structure. - The supraspinous ligament lies superficial to the interspinous ligament, both of which are encountered before the ligamentum flava. *Skin* - The skin is the very first layer pierced when performing a lumbar puncture. - The question is asking what is pierced after the interspinous ligament, not what is pierced first. *Sub cutaneous fascia* - The subcutaneous fascia is located directly beneath the skin and is encountered very early in the lumbar puncture procedure. - It lies superficial to all ligaments of the vertebral column, including the interspinous ligament. *Dura mater* - The dura mater is pierced after the ligamentum flava. - It is the outermost meningeal layer, which, once penetrated, indicates entry into the epidural space, followed by the subarachnoid space. *Arachnoid mater* - The arachnoid mater is a thin, delicate membrane that lies immediately deep to the dura mater. - It is pierced almost simultaneously with the dura mater, and its penetration allows entry into the subarachnoid space where CSF is collected. *Return of CSF* - The return of CSF is the result of successfully traversing all necessary layers and entering the subarachnoid space. - It is not an anatomical structure that is pierced itself, but rather the clinical endpoint of the procedure.

Question 3: Which of the following structures is not found in the parotid gland?

A. Buccal branch of mandibular nerve (Correct Answer)
B. Facial nerve
C. ECA
D. Auriculotemporal nerve

Explanation: ***Buccal branch of mandibular nerve*** - The **buccal branch of the mandibular nerve (V3)** is not found within the parotid gland. It innervates the buccinator muscle and provides sensory innervation to the buccal mucosa. - The facial nerve, after exiting the stylomastoid foramen, branches within the parotid gland, but the *mandibular nerve* and its branches are distinct structures. *ECA* - The **external carotid artery (ECA)** runs *through* the parotid gland before dividing into its terminal branches, the superficial temporal and maxillary arteries. - This is a major landmark for surgeons operating on the parotid gland. *Facial nerve* - The **facial nerve (cranial nerve VII)** enters the parotid gland and then divides into its five terminal branches (temporal, zygomatic, buccal, marginal mandibular, cervical) *within* the gland. - These branches are responsible for innervating the muscles of facial expression. *Auriculotemporal nerve* - The **auriculotemporal nerve**, a branch of the mandibular nerve (V3), travels *through* the parotid gland. - It carries postganglionic parasympathetic fibers from the otic ganglion to the parotid gland, providing secretomotor innervation.

Question 4: You evaluate an 18 yrs old male who sustained a right sided cervical laceration during a gang fight. Which of the following is a relative rather than an absolute indication for neck exploration?

A. Dysphonia
B. Expanding hematoma
C. Pneumothorax (Correct Answer)
D. Dysphagia

Explanation: ***Pneumothorax*** - A pneumothorax, while concerning, can often be managed with a **chest tube** insertion without immediate surgical exploration, making it a relative indication. - Its presence suggests potential compromise to structures in the neck/chest but doesn't always mandate direct surgical wound exploration as a first step. *Dysphonia* - **Hoarseness or difficulty speaking** after a neck injury suggests potential direct laryngeal, tracheal, or recurrent laryngeal nerve injury, warranting exploration to assess and repair. - This symptom implies a direct compromise of the **airway or critical nerves**, making exploration more immediate. *Expanding hematoma* - An **expanding hematoma** indicates active, potentially life-threatening bleeding and/or mass effect, which can compromise the airway or blood supply to the brain. - This is an **absolute indication for immediate surgical exploration** to control hemorrhage and prevent airway obstruction. *Dysphagia* - **Difficulty swallowing** post-neck trauma suggests injury to the pharynx or esophagus. - Such injuries carry a significant risk of **mediastinitis** or sepsis if not promptly identified and repaired via surgical exploration.

Question 5: Cause of Ludwig angina is:

A. Retropharyngeal abscess
B. Tooth infection (Correct Answer)
C. Parotid abscess
D. Tonsillitis

Explanation: ***Tooth infection*** - **Odontogenic infections**, particularly from the mandibular molars (especially 2nd and 3rd molars), are the most common cause of Ludwig's angina, accounting for **70-90% of cases**. - These infections spread contiguously from the **apex of the tooth** through the thin lingual cortex into the submandibular and sublingual spaces. - The infection causes **bilateral cellulitis** of the floor of the mouth with characteristic "bull neck" appearance. *Retropharyngeal abscess* - A retropharyngeal abscess forms in the **potential space between the pharynx and prevertebral fascia**. - While it can cause airway compromise and neck swelling, it's anatomically distinct from Ludwig's angina, which involves the **submandibular, sublingual, and submental spaces**. - Retropharyngeal abscess typically presents with dysphagia, neck stiffness, and fever. *Parotid abscess* - A parotid abscess is an infection of the **parotid gland**, located superficially in the preauricular region. - It causes swelling anterior to the ear and along the **mandibular angle**, not the floor of the mouth. - It does not involve the submandibular/sublingual spaces and does not cause the bilateral "board-like" induration characteristic of Ludwig's angina. *Tonsillitis* - While tonsillar infections can occasionally spread to deep neck spaces, they typically cause **peritonsillar abscess** (quinsy). - Tonsillitis rarely causes Ludwig's angina unless there is direct extension through the pharyngeal wall, which is uncommon. - The anatomical distance between the tonsillar fossa and the submandibular space makes this an unlikely cause.

Question 6: Which of the following statements about Sibson's fascia is correct?

A. Part of scalenus anterior muscle
B. Vessel pass above the fascia
C. Covers apical part of lung (Correct Answer)
D. Attached to the inner border of 2nd rib

Explanation: ***Covers apical part of lung*** - **Sibson's fascia**, also known as the **suprapleural membrane**, is a dense fascial layer that covers and reinforces the **apex of the lung** and pleura. - It protects the lung apex and helps to support structures in the **root of the neck**. *Part of scalenus anterior muscle* - Sibson's fascia is a **separate fascial structure** extending from the first rib to the C7 transverse process, and is not a part of the scalenus anterior muscle. - The **scalenus anterior muscle** is one of the muscles of the neck, and while anatomically related by proximity to the fascia, it is not structurally part of it. *Vessel pass above the fascia* - Key neurovascular structures like the **subclavian artery** and the **brachial plexus** pass *below* Sibson's fascia, as the fascia protects the lung apex. - The fascia acts as a barrier, separating the lung apex from the more superficial structures of the neck. *Attached to the inner border of 2nd rib* - Sibson's fascia is primarily attached to the **inner border of the first rib** and the transverse process of the seventh cervical vertebra. - Its attachment to the first rib is crucial for its supportive role over the lung apex.

Question 7: Sitaram a 40-year old man, met with an accident and comes to emergency department with engorged neck veins, pallor, rapid pulse and chest pain Diagnosis is -

A. Pulmonary laceration (lung injury)
B. Splenic rupture (abdominal trauma)
C. Hemothorax (blood in the pleural cavity)
D. Cardiac tamponade (fluid accumulation in the pericardium) (Correct Answer)

Explanation: ***Cardiac tamponade (fluid accumulation in the pericardium)*** - **Engorged neck veins (elevated JVP)**, **pallor** (due to decreased cardiac output), and a **rapid pulse** ("pulsus paradoxus" or tachycardia from compensatory mechanisms) in the context of trauma are classic signs of **cardiac tamponade**. - **Chest pain** can result from the acute compression of the heart, leading to reduced ventricular filling and cardiac output. *Pulmonary laceration (lung injury)* - A pulmonary laceration would primarily present with **respiratory distress**, **hemoptysis**, and potential **air leak syndromes** (e.g., pneumothorax), not typically engorged neck veins as a primary sign. - While it can cause chest pain and rapid pulse, it doesn't explain the combination of engorged neck veins and significant cardiovascular compromise seen here without other prominent respiratory symptoms. *Splenic rupture (abdominal trauma)* - Splenic rupture typically presents with **left upper quadrant abdominal pain**, **abdominal tenderness**, and signs of **hypovolemic shock** (pallor, rapid pulse, hypotension), but not generally engorged neck veins. - The primary location of trauma and symptoms would be abdominal, not chest pain and engorged neck veins. *Hemothorax (blood in the pleural cavity)* - A hemothorax would cause **chest pain**, **dyspnea**, **diminished breath sounds** on the affected side, and signs of **hypovolemic shock** if severe (pallor, rapid pulse). - However, it typically leads to **collapsed neck veins** due to hypovolemia, rather than engorged neck veins, unless there's a co-existing tension pneumothorax or cardiac tamponade.

Question 8: Which statement considering the relations of nerves to the humerus is the most accurate?

A. Deltoid may atrophy following shoulder dislocation. (Correct Answer)
B. The median nerve runs in the spiral groove.
C. The axillary nerve runs around the anatomical neck.
D. Mid-shaft humeral fractures will usually result in complete paralysis of triceps.

Explanation: **Deltoid may atrophy following shoulder dislocation.** - **Shoulder dislocations**, particularly anterior dislocations, frequently injure the **axillary nerve** due to its close proximity to the humeral head and surgical neck. - Damage to the axillary nerve, which innervates the **deltoid muscle**, can lead to deltoid paralysis and subsequent **atrophy**, resulting in a flattened shoulder contour and impaired abduction. *The median nerve runs in the spiral groove.* - The **radial nerve**, not the median nerve, runs in the **spiral groove** (radial groove) of the humerus [1]. - The median nerve travels more anteriorly in the arm, alongside the brachial artery. *The axillary nerve runs around the anatomical neck.* - The **axillary nerve** wraps around the **surgical neck** of the humerus, not the anatomical neck. - The surgical neck is a common site for fractures, making the axillary nerve vulnerable to injury in such cases. *Mid-shaft humeral fractures will usually result in complete paralysis of triceps.* - Mid-shaft humeral fractures primarily risk damage to the **radial nerve**, which innervates the lateral and medial heads of the triceps [1]. - However, the **long head of the triceps** is innervated by the radial nerve more proximally and may remain partially functional, preventing complete paralysis of the entire triceps muscle.

Question 9: Secondaries in the neck with no obvious primary malignancy is most often due to which of the following?

A. Carcinoma of the Stomach
B. Carcinoma of the Larynx
C. Carcinoma of the Nasopharynx (Correct Answer)
D. Carcinoma of the Thyroid

Explanation: **Explanation:** The clinical scenario of "Secondary in the neck with an unknown primary" refers to a metastatic cervical lymph node where the initial site of malignancy is not clinically apparent. **Why Nasopharynx is the correct answer:** Carcinoma of the Nasopharynx is notorious for being "clinically silent" in its early stages. Due to its anatomical location in the fossa of Rosenmüller, the primary tumor often remains small and asymptomatic while early lymphatic spread occurs. In approximately **50-60% of cases**, a painless neck swelling (usually involving the upper deep cervical or Level V nodes) is the first and only presenting symptom. This makes it the most common site for an occult primary in the head and neck region. **Analysis of Incorrect Options:** * **Carcinoma of the Stomach:** While it can metastasize to the left supraclavicular node (Virchow’s node/Troisier’s sign), it is a distant metastasis (Stage IV) and usually presents with significant constitutional or GI symptoms. * **Carcinoma of the Larynx:** These tumors typically present early with symptoms like hoarseness of voice (glottic) or throat pain/dysphagia (supraglottic), making the primary site "obvious" rather than occult. * **Carcinoma of the Thyroid:** While it frequently spreads to cervical nodes (especially papillary variety), the primary thyroid nodule is usually palpable or easily detected on initial physical examination. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of occult primary:** Nasopharynx (followed by Palatine Tonsil and Base of Tongue). * **Diagnostic Gold Standard:** Fine Needle Aspiration Cytology (FNAC) is the first-line investigation for the neck mass. * **Work-up:** If the primary is not found on physical exam, the next steps include **CECT/MRI** from skull base to clavicle and **Panendoscopy** (Direct laryngoscopy, Esophagoscopy, and Bronchoscopy) with guided biopsies. * **EBV Association:** Nasopharyngeal carcinoma is strongly associated with the Epstein-Barr Virus.

Question 10: What clinical appearance is associated with bilateral TMJ ankylosis?

A. Bird face appearance
B. Vogel gesicht appearance
C. Andy gump appearance
D. All of the above (Correct Answer)

Explanation: **Explanation:** Bilateral Temporomandibular Joint (TMJ) ankylosis, especially when it occurs during the developmental years, leads to a characteristic facial deformity due to the failure of mandibular growth. **1. Why "All of the above" is correct:** The terms **Bird face appearance**, **Vogel gesicht appearance**, and **Andy Gump appearance** are all synonymous in clinical ENT and Maxillofacial surgery to describe the same morphological profile. * **Bird face / Vogel gesicht:** "Vogel gesicht" is simply the German translation for "Bird face." It describes the profile where the mandible is severely retruded (micrognathia/retrognathia), making the nose appear prominent and the face resemble a bird. * **Andy Gump appearance:** Named after a famous 1920s comic strip character, this term refers to the severe receding chin (retrognathia) seen in these patients. **2. Pathophysiology:** The mandibular condyle is the primary growth center of the mandible. Bilateral ankylosis results in the cessation of forward and downward growth of the lower jaw. This leads to: * Micrognathia (small jaw) and Retrognathia (receded jaw). * Secondary features like "Antegonial notching" and a double chin appearance. **3. High-Yield Clinical Pearls for NEET-PG:** * **Unilateral Ankylosis:** Results in facial asymmetry with the chin deviating **towards** the affected side. * **Bilateral Ankylosis:** Results in symmetrical recession (Bird face) without deviation. * **Most common cause:** Trauma (especially birth trauma or falls on the chin) followed by infections (Otitis media). * **Treatment:** Gap arthroplasty or Interpositional arthroplasty. Early surgery is crucial to prevent permanent growth restriction. * **Airway Concern:** These patients are difficult to intubate (Difficult Airway) due to limited mouth opening and retrognathia.

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