Airway Management in Head and Neck Surgery — MCQs
Laryngeal mask airway [LMA] is contraindicated in?
A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
A Patient in medical intensive care unit who is intubated, suddenly removes the endotracheal tube. What should be done next?
Modified Mallampati grading is used in assessment of -
The safest initial approach to open the airway of a patient with maxillofacial trauma is:
Emergency tracheostomy is not indicated in
What is the most common indication for performing a tracheostomy?
Treatment of resectable T4N0M0 stage of head and neck carcinoma is?
N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:
Supraomohyoid dissection is a type of?
Airway Management in Head and Neck Surgery Indian Medical PG Practice Questions and MCQs
Question 1: Laryngeal mask airway [LMA] is contraindicated in?
- A. Ocular surgeries
- B. Pregnant female (Correct Answer)
- C. Difficult airways
- D. In CPR
Explanation: ***Pregnant female*** - **Pregnant patients** are at an increased risk of **gastric reflux and aspiration pneumonitis** due to decreased lower esophageal sphincter tone and increased intra-abdominal pressure. - The LMA does not provide a secure airway seal against aspiration, making it contraindicated in cases where **aspiration risk is high**, such as pregnancy or full stomach. *Difficult airways* - The LMA is often considered a **rescue device** in difficult airway algorithms when tracheal intubation fails. - It can be used as a conduit for **fiberoptic intubation** or as a temporary airway while preparing for a definitive airway. *Ocular surgeries* - LMAs are generally suitable for ocular surgeries as they provide a stable airway without the use of a mask, which can obstruct the surgical field. - They tend to cause **less coughing and straining** upon insertion and maintenance compared to endotracheal tubes, which is beneficial in preventing increases in intraocular pressure. *In CPR* - The LMA can be an effective airway device during **cardiopulmonary resuscitation (CPR)** when endotracheal intubation is not immediately feasible. - It provides a relatively quick and easy way to establish an airway, facilitate ventilation, and reduce the risk of gastric insufflation during chest compressions.
Question 2: A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
- A. FB in larynx
- B. Angioneurotic edema (Correct Answer)
- C. Parapharyngeal abscess
- D. FB bronchus
Explanation: Andioneurotic edema - The combination of **tongue swelling**, **neck swelling**, **stridor**, and **hoarseness of voice** following peanut ingestion is highly suggestive of **angioneurotic edema**, a severe allergic reaction that can lead to airway obstruction [1]. - This is a life-threatening condition requiring immediate medical intervention, often associated with generalized **anaphylaxis** when triggered by allergens [2]. *FB in larynx* - While a **foreign body (FB) in the larynx** can cause stridor and hoarseness, the widespread swelling of the tongue and neck points away from a localized laryngeal obstruction [3]. - A laryngeal FB would typically be associated with a more sudden onset of choking and coughing, not diffuse edema [3]. *Parapharyngeal abscess* - A **parapharyngeal abscess** would typically present with **fever**, **severe throat pain**, and **trismus** (difficulty opening the mouth), which are not mentioned in this scenario. - The acute, rapid onset of symptoms after peanut consumption is inconsistent with the slower progression of an abscess. *FB bronchus* - A **foreign body in the bronchus** would primarily cause **coughing**, **wheezing**, and possibly **respiratory distress**, often unilateral, rather than severe global swelling of the tongue and neck. - Inspiratory stridor and hoarseness are more indicative of upper airway involvement than bronchial obstruction.
Question 3: A Patient in medical intensive care unit who is intubated, suddenly removes the endotracheal tube. What should be done next?
- A. Sedate and reintubate
- B. Make him sit and do physiotherapy
- C. Assess the patient and give bag and mask ventilation and look for spontaneous breathing (Correct Answer)
- D. Give bag and mask ventilation and intubate
Explanation: ***Assess the patient and give bag and mask ventilation and look for spontaneous breathing*** - Upon accidental extubation, the immediate priority is to **assess the patient's airway, breathing, and circulation (ABCs)** and ensure oxygenation via **bag-mask ventilation** if needed, while observing for spontaneous breathing efforts. - This step allows for a controlled re-evaluation of the patient's respiratory status and provides time to plan for reintubation if indicated, without rushing into sedating or reintubating a potentially stable patient. *Sedate and reintubate* - While reintubation may ultimately be necessary, sedating and immediately attempting reintubation without prior assessment can be dangerous if the patient has **stable spontaneous breathing** or if there are other contributing factors like **airway swelling** that need to be addressed first. - Rushing to sedate and intubate could lead to complications if the patient's physiology is not fully understood post-extubation. *Make him sit and do physiotherapy* - This option is inappropriate for an intubated patient who has just accidentally self-extubated, as their airway and breathing status are of immediate concern. - Positioning for physiotherapy or performing chest physiotherapy is a secondary concern after ensuring **adequate oxygenation and ventilation** and confirming a stable airway. *Give bag and mask ventilation and intubate* - While bag-mask ventilation is an appropriate immediate step to maintain oxygenation, automatically proceeding to intubation without fully **assessing the patient's spontaneous breathing status** and overall stability is premature. - Some patients might tolerate extubation and breathe adequately on their own, negating the need for immediate reintubation.
Question 4: Modified Mallampati grading is used in assessment of -
- A. Difficulty of intubation (Correct Answer)
- B. Obstruction of the airway
- C. Aspiration-related death
- D. Endotracheal intubation procedure
Explanation: ***Difficulty of intubation*** - The **Modified Mallampati score** assesses the visibility of pharyngeal structures, which directly correlates with the ease or difficulty of performing **direct laryngoscopy** and **endotracheal intubation**. - A higher Mallampati class (e.g., III or IV) indicates less visibility of the soft palate, uvula, and pillars, suggesting a more difficult airway and increased likelihood of a challenging intubation. *Obstruction of the airway* - While a high Mallampati score might indirectly indicate potential for **airway obstruction** during anesthesia due to anatomical features, its primary purpose is not to diagnose or quantify existing airway obstruction. - Airway obstruction is more directly assessed by monitoring breathing sounds, respiratory effort, and oxygen saturation. *Aspiration-related death* - The **Mallampati score** helps predict the difficulty of securing the airway but does not directly assess the risk of **aspiration**. - Aspiration risk is evaluated based on factors like gastric contents, gag reflex, and patient positioning. *Endotracheal intubation procedure* - The **Modified Mallampati score** helps in **planning the intubation procedure** by identifying potential difficulties but is not a measure of the intubation procedure itself. - It is a **pre-procedure assessment tool** to gauge airway anatomy, not a description or evaluation of the steps involved in endotracheal intubation.
Question 5: The safest initial approach to open the airway of a patient with maxillofacial trauma is:
- A. Head tilt-chin lift
- B. Jaw thrust technique (Correct Answer)
- C. Head lift-neck lift
- D. Heimlich procedure
Explanation: ***Jaw thrust technique*** - This technique is preferred in cases of **maxillofacial or suspected cervical spine trauma** as it minimizes neck movement, thereby reducing the risk of further injury. - It involves grasping the angles of the mandible and **lifting the jaw anteriorly**, which moves the tongue away from the posterior pharynx to clear the airway. *Head tilt-chin lift* - This maneuver is contraindicated in trauma settings where a **cervical spine injury** is suspected, as it can extend the neck and exacerbate spinal cord damage. - While effective for opening the airway in non-trauma patients, it involves **significant neck movement** which is unsafe in maxillofacial trauma. *Head lift-neck lift* - This is not a recognized or safe technique for airway management, especially in trauma patients, as it would cause **unnecessary and potentially harmful movement** of the head and neck. - There is no clinical scenario where this technique would be recommended over established airway maneuvers. *Heimlich procedure* - The Heimlich procedure (abdominal thrusts) is used to relieve **severe foreign body airway obstruction** and is not an initial approach to open an airway due to general trauma. - It is an intervention for choking, not for managing an airway in a patient with maxillofacial trauma where the primary concern is often **tongue prolapse** or significant structural injury causing obstruction.
Question 6: Emergency tracheostomy is not indicated in
- A. Bilateral vocal cord paralysis
- B. Foreign body larynx
- C. Acute severe asthma (Correct Answer)
- D. Stridor due to laryngeal growth
Explanation: ***Acute severe asthma*** - While life-threatening, acute severe asthma is primarily managed with **bronchodilators**, **steroids**, and potentially **non-invasive or invasive ventilation**. - **Tracheostomy** is generally reserved for situations involving upper airway obstruction that cannot be managed by other means, which is not the primary issue in asthma. *Bilateral vocal cord paralysis* - This condition can cause severe **upper airway obstruction** due to the adduction of both vocal cords. - In an emergency setting, a tracheostomy may be life-saving to bypass the obstructed larynx. *Foreign body larynx* - An obstructing **foreign body in the larynx** can lead to immediate and complete airway compromise. - If efforts like the **Heimlich maneuver** or direct laryngoscopy with removal fail, an emergency tracheostomy might be necessary. *Stridor due to laryngeal growth* - A laryngeal growth causing **stridor** indicates significant airway narrowing, which can acutely worsen and lead to respiratory distress. - In cases of severe or rapidly progressive obstruction, an **emergency tracheostomy** is needed to secure the airway below the level of the growth.
Question 7: What is the most common indication for performing a tracheostomy?
- A. Severe obstructive sleep apnea
- B. Tracheal stenosis
- C. Vocal cord paralysis
- D. Prolonged mechanical ventilation (Correct Answer)
Explanation: ***Prolonged mechanical ventilation*** - Maintaining an **endotracheal tube** for an extended period carries risks like **tracheal injury**, **vocal cord damage**, and difficulty with oral intake. - A tracheostomy provides a more comfortable and stable airway for **long-term respiratory support**, facilitates weaning from the ventilator, and reduces the risk of **ventilator-associated pneumonia**. *Severe obstructive sleep apnea* - While tracheostomy can effectively treat severe OSA by bypassing the upper airway obstruction, it is generally considered a **last resort** after less invasive treatments have failed. - The most common initial treatments for OSA include **CPAP**, weight loss, and oral appliances. *Tracheal stenosis* - Tracheal stenosis itself is a **structural narrowing** of the trachea that may or may not require tracheostomy, depending on its severity and location. - While a tracheostomy can bypass a severe stenosis, surgical repair of the trachea is often the definitive treatment for **severe tracheal stenosis**. *Vocal cord paralysis* - Unilateral vocal cord paralysis typically causes **hoarseness** and may not always necessitate a tracheostomy. - Bilateral vocal cord paralysis can lead to **airway obstruction**, but intervention usually involves vocal cord lateralization procedures or, in severe cases, a tracheostomy for airway patency.
Question 8: Treatment of resectable T4N0M0 stage of head and neck carcinoma is?
- A. Radiotherapy alone
- B. Surgery and Radiotherapy (Correct Answer)
- C. Chemoradiation
- D. Surgery alone
Explanation: ***Surgery and Radiotherapy*** - For **resectable T4N0M0 head and neck carcinoma**, the standard treatment is **surgical resection** of the primary tumor followed by **adjuvant radiotherapy**. - This approach achieves optimal **local control** for advanced primary tumors without nodal involvement. - **Adjuvant radiotherapy** is essential for T4 tumors due to high risk of microscopic residual disease and local recurrence. - Surgery allows for complete tumor removal with negative margins, while radiotherapy addresses subclinical disease. *Radiotherapy alone* - Radiotherapy alone is **insufficient as monotherapy** for T4 tumors due to the large tumor burden and extensive local invasion. - Single modality radiation cannot reliably achieve adequate tumor control for advanced primary lesions. - Generally reserved for early-stage disease or patients unfit for surgery. *Chemoradiation* - **Definitive chemoradiation** is an alternative for **unresectable T4 tumors** or when organ preservation is desired (e.g., laryngeal cancer). - For **resectable** T4N0M0 disease, surgery with adjuvant RT is preferred as it provides better local control and allows pathological staging. - Chemoradiation may be used postoperatively if high-risk features are found (positive margins, perineural invasion, extranodal extension). - In this **N0 case with resectable tumor**, upfront surgery is the preferred initial approach. *Surgery alone* - While surgical resection is crucial for T4 tumors, **surgery alone is inadequate** due to high risk of locoregional recurrence. - T4 classification indicates extensive local invasion, necessitating **adjuvant radiotherapy** to eradicate microscopic disease. - Combined modality treatment (surgery + RT) significantly improves local control and survival compared to surgery alone.
Question 9: 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
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.
Question 10: Supraomohyoid dissection is a type of?
- A. Selective neck dissection (Correct Answer)
- B. Modified radical neck dissection
- C. Radical neck dissection
- D. Posterolateral dissection
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.
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