Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 91: What is the most appropriate treatment for facial nerve injury in a lateral facial wound?

A. Secondary repair
B. Primary repair (Correct Answer)
C. Secondary repair with grafting
D. Healing with secondary intention

Explanation: In facial trauma, the management of facial nerve injury depends on the timing and nature of the wound. **Why Primary Repair is Correct:** The facial nerve is a purely motor nerve (distal to the stylomastoid foramen), and its regeneration potential is excellent. **Primary repair (neurorrhaphy)**, performed within **72 hours** of injury, is the gold standard for clean-cut lateral facial wounds. At this stage, the distal ends of the nerve can still be identified using a nerve stimulator (Wallerian degeneration is not yet complete), and there is minimal scarring or retraction, allowing for a tension-free, end-to-end anastomosis. **Explanation of Incorrect Options:** * **Secondary Repair (A & C):** This is reserved for cases with significant tissue loss, heavy contamination, or when the patient is hemodynamically unstable. Delaying repair leads to proximal stump neuroma and distal stump fibrosis, making identification difficult and outcomes poorer. * **Secondary Repair with Grafting (C):** This is only indicated if a primary tension-free repair is impossible due to a large nerve gap (usually >1-2 cm). * **Healing with Secondary Intention (D):** This is never appropriate for a transected nerve, as it leads to permanent facial paralysis and muscle atrophy. **NEET-PG High-Yield Pearls:** * **The 72-Hour Rule:** Nerve stimulation of the distal stump is possible for up to 3 days post-injury. * **The Vertical Line Rule:** Injuries **medial** to a vertical line dropped from the lateral canthus of the eye often do not require surgical repair, as there is significant plexiform branching and spontaneous recovery is common. * **Suture Material:** Micro-neurosurgical repair is typically done using 9-0 or 10-0 monofilament (Nylon) sutures. * **Best Prognosis:** Primary end-to-end repair always yields better functional results than nerve grafting.

Question 92: A 40-year-old female presented with a progressively increasing lump in the parotid region. On oral examination, the tonsil was pushed medially. Biopsy showed it to be pleomorphic adenoma. What is the appropriate treatment?

A. Superficial parotidectomy
B. Lumpectomy
C. Conservative total parotidectomy (Correct Answer)
D. Enucleation

Explanation: ### Explanation **1. Why "Conservative Total Parotidectomy" is correct:** The clinical hallmark in this case is the **medial displacement of the tonsil**. This indicates that the tumor is arising from the **deep lobe** of the parotid gland. The parotid gland is divided into superficial and deep lobes by the plane of the facial nerve (Patey’s separation). While most pleomorphic adenomas occur in the superficial lobe, those in the deep lobe expand through the stylomandibular tunnel into the parapharyngeal space, pushing the lateral pharyngeal wall and tonsil medially (the "dumbbell" tumor). The standard treatment for a deep lobe pleomorphic adenoma is **Conservative Total Parotidectomy**. "Conservative" refers to the **preservation of the facial nerve**, while "Total" implies the removal of both the superficial and deep lobes to ensure adequate margins and safe nerve dissection. **2. Why other options are incorrect:** * **Superficial Parotidectomy:** This is the treatment of choice for tumors confined to the superficial lobe. It would not address a tumor causing tonsillar displacement. * **Lumpectomy/Enucleation:** These are contraindicated for pleomorphic adenoma. Because the tumor has a "false capsule" with microscopic finger-like projections (pseudopods), simple enucleation leads to high recurrence rates (up to 50%) and potential seeding. **3. Clinical Pearls for NEET-PG:** * **Most common parotid tumor:** Pleomorphic adenoma (Benign Mixed Tumor). * **Facial Nerve Plane:** The nerve lies between the superficial and deep lobes. The **Stylomastoid foramen** is the exit point, and the **Tragal pointer** is a key surgical landmark to locate it. * **Frey’s Syndrome:** A common complication after parotidectomy (auriculotemporal nerve injury leading to gustatory sweating). * **Malignancy Sign:** If a parotid mass presents with facial nerve palsy, suspect **Mucoepidermoid carcinoma** (most common malignancy) or Adenoid cystic carcinoma.

Question 93: Adamantinoma arises from which of the following?

A. Dental lamina
B. Endothelium
C. Odontogenic tissue (Correct Answer)
D. Basal oral mucosa

Explanation: **Explanation:** **Adamantinoma** (classically known as **Ameloblastoma**) is a slow-growing, locally invasive, but usually benign epithelial odontogenic tumor. **1. Why the correct answer is right:** Ameloblastomas arise from **odontogenic tissue**, specifically the remnants of the **dental lamina** (rests of Serres) or the **enamel organ** (rests of Malassez). These are the tissues responsible for tooth formation. Because it originates from these specialized cells, it is most commonly found in the mandible (80%), particularly in the molar-ramus region. **2. Analysis of incorrect options:** * **Dental lamina (Option A):** While the dental lamina is the specific precursor, "Odontogenic tissue" is the broader, more standard classification used in pathology for this tumor. In many exams, if both are present, the general tissue category (Odontogenic) is the preferred answer. * **Endothelium (Option B):** Endothelium gives rise to vascular tumors like hemangiomas or angiosarcomas, not epithelial tumors of the jaw. * **Basal oral mucosa (Option C):** While some theories suggest a peripheral origin from the oral epithelium, the primary and classic origin is the deeper odontogenic apparatus. **3. Clinical Pearls for NEET-PG:** * **Radiological Appearance:** Characteristically shows a **"Soap-bubble"** or **"Honey-comb"** appearance due to multilocular radiolucency. * **Clinical Feature:** It causes expansion of the jaw bone, leading to **"Egg-shell crackling"** on palpation. * **Management:** It is radioresistant. The treatment of choice is **wide local excision** with at least 1 cm of healthy bone margin to prevent high recurrence rates. * **Note on Extragnathic Adamantinoma:** A histologically similar but distinct tumor called "Adamantinoma of long bones" occurs most commonly in the **Tibia**, but this is not odontogenic in origin.

Question 94: A man presented with a slow-growing, asymptomatic, firm, non-tender, pulsatile mass in the region of the carotid bifurcation. Diagnosis was made as carotid body tumor by angiogram. Where does a carotid body tumor arise from?

A. Carotid sinus
B. Carotid artery
C. Parasympathetic paraganglioma (Correct Answer)
D. Sympathetic paraganglioma

Explanation: **Explanation:** **Carotid Body Tumor (CBT)**, also known as a **chemodectoma**, is the most common head and neck paraganglioma. It arises from the **parasympathetic paraganglia** located at the bifurcation of the common carotid artery. These cells are derived from the **neural crest** and function as chemoreceptors sensitive to changes in arterial oxygen, carbon dioxide, and pH. * **Why Option C is correct:** Paragangliomas are classified based on their anatomical location and autonomic association. Head and neck paragangliomas (like carotid body, glomus jugulare, and glomus tympanicum) are almost exclusively **parasympathetic** in origin. Unlike sympathetic paraganglia, they are usually non-secretory (do not produce catecholamines). * **Why Option D is incorrect:** Sympathetic paragangliomas typically arise in the abdomen or thorax (e.g., Organ of Zuckerkandl) and are frequently associated with catecholamine secretion (hypertension, palpitations). * **Why Options A & B are incorrect:** While the tumor is located at the carotid bifurcation near the **carotid sinus** (a baroreceptor), it does not arise from the sinus tissue itself or the vessel wall of the **carotid artery**. It is a neuroendocrine tumor arising from the specialized cells *between* the vessels. **High-Yield Clinical Pearls for NEET-PG:** * **Fontaine’s Sign:** The mass is mobile horizontally but fixed vertically (due to its attachment to the carotid bifurcation). * **Lyre Sign:** On angiography, the tumor causes characteristic widening/splaying of the internal and external carotid arteries. * **Shamblin Classification:** Used to grade the tumor based on its degree of encirclement of the carotid vessels. * **Rule of 10s:** Approximately 10% are bilateral, 10% are malignant, and 10% are familial (associated with SDH gene mutations).

Question 95: A 32-year-old female, with a history of chronic tobacco chewing since 14 years of age, presents with difficulty in opening her mouth. On oral examination, no ulcers are seen. What is the most probable diagnosis?

A. Submucous oral fibrosis (Correct Answer)
B. Carcinoma of the tongue
C. Trigeminal nerve paralysis
D. Carcinoma of the buccal mucosa

Explanation: ### Explanation **Correct Answer: A. Submucous oral fibrosis (OSMF)** **Why it is correct:** Oral Submucous Fibrosis (OSMF) is a chronic, progressive, premalignant condition characterized by juxta-epithelial inflammatory reaction followed by **fibroelastic change** of the lamina propria. * **Etiology:** It is strongly associated with areca nut and tobacco chewing. * **Clinical Presentation:** The hallmark feature is **progressive trismus** (difficulty in opening the mouth) due to the formation of vertical fibrous bands in the buccal mucosa and soft palate. * **Physical Exam:** The mucosa appears blanched, opaque, and "marble-like." The absence of ulcers in this clinical scenario, combined with the long-term history of tobacco use and restricted mouth opening, makes OSMF the most probable diagnosis. **Why the other options are incorrect:** * **B & D (Carcinoma of the tongue/buccal mucosa):** While tobacco is a risk factor for oral malignancy, these typically present with a non-healing ulcer, an exophytic growth, or indurated plaques. While advanced stages can cause trismus (via infiltration of masticatory muscles), the absence of an ulcer or mass in a 32-year-old makes OSMF more likely. * **C (Trigeminal nerve paralysis):** The trigeminal nerve (CN V3) provides motor supply to the muscles of mastication. Paralysis would lead to **weakness** in closing the jaw or deviation of the jaw to the affected side, rather than a mechanical restriction in opening (trismus). **High-Yield Clinical Pearls for NEET-PG:** * **Pathogenesis:** Alkaloids (Arecoline) in areca nuts stimulate fibroblasts to increase collagen synthesis, while flavonoids inhibit collagenase, leading to net fibrosis. * **Staging:** The severity is often measured by the **Inter-incisor distance** (Normal: 35–50 mm). * **Pre-malignant potential:** OSMF has a high malignant transformation rate (approx. 7–13%). * **Treatment:** Cessation of habit, intralesional steroids (to reduce inflammation), and hyaluronidase (to break down collagen). Surgical release of bands is reserved for severe cases.

Question 96: Seabrooks operation is done for which condition?

A. Parotid gland pathologies (Correct Answer)
B. Thyroglossal fistula
C. Thyroglossal cyst
D. Branchial fistula

Explanation: **Explanation:** **Seabrook’s operation** is a surgical technique used for the management of **parotid gland pathologies**, specifically for the treatment of a **parotid fistula**. A parotid fistula occurs when saliva leaks from the parotid gland or its duct (Stensen’s duct) onto the skin surface, usually following trauma or surgery. Seabrook’s procedure involves the **re-routing of the proximal end of the parotid duct into the oral cavity**, thereby converting an external fistula into an internal one. **Analysis of Incorrect Options:** * **Thyroglossal Cyst & Fistula (Options B & C):** The gold standard treatment for these conditions is the **Sistrunk operation**, which involves the excision of the cyst/fistula track along with the central portion of the hyoid bone to prevent recurrence. * **Branchial Fistula (Option D):** This is typically managed by a **stepladder incision** (two transverse incisions) to completely dissect the long tract extending from the skin to the oropharynx (usually the second branchial arch remnant). **High-Yield Clinical Pearls for NEET-PG:** * **Frey’s Syndrome:** A common complication after parotid surgery (injury to the auriculotemporal nerve) characterized by gustatory sweating. It is diagnosed by the **Minor’s Starch-Iodine test**. * **Modified Blair’s Incision:** The standard surgical approach used for a superficial or total parotidectomy. * **Stensen’s Duct:** Opens into the oral cavity opposite the crown of the **upper second molar tooth**. * **Sistrunk Operation:** High-yield for its association with the **hyoid bone** removal.

Question 97: According to Sawhney's classification of TMJ ankylosis, which type is characterized by complete destruction of joint architecture by osseous union with no identifiable sigmoid notch?

A. Type 1
B. Type 2
C. Type 3
D. Type 4 (Correct Answer)

Explanation: ### Explanation **Sawhney’s Classification** is the most widely used system to categorize the severity of Temporomandibular Joint (TMJ) ankylosis based on radiological and clinical findings. **Correct Option: D (Type 4)** In **Type 4 ankylosis**, there is complete destruction of the joint architecture. The condyle, notch, and coronoid process are replaced by a massive, solid block of bone (synostosis) extending from the ramus to the zygomatic arch. The **sigmoid notch is completely obliterated**, making this the most severe form. **Analysis of Incorrect Options:** * **Type 1 (Option A):** Characterized by minimal bone formation. There is a flattening or deformity of the condyle with fibrous adhesions, but the joint space is still visible. * **Type 2 (Option B):** Features more extensive bony fusion, typically involving the outer surface of the joint. However, the **medial part of the joint remains relatively unaffected**, and the anatomy of the condyle is still somewhat recognizable. * **Type 3 (Option C):** There is a bony bridge (ankylotic mass) connecting the ramus to the zygomatic arch. Crucially, the **sigmoid notch is still identifiable**, and a small portion of the original condylar head may be seen medially. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Trauma (specifically undiagnosed/untreated condylar fractures) is the leading cause of TMJ ankylosis, followed by infections (Otitis media). * **Clinical Presentation:** Progressive limitation of mouth opening (trismus), facial asymmetry (if unilateral), and "bird-face" deformity (micrognathia) if bilateral and occurring during growth. * **Treatment Gold Standard:** Gap arthroplasty or Interpositional arthroplasty (using temporalis fascia or cartilage) to prevent re-ankylosis. * **Radiology:** The "Panorex" (OPG) and CT scans are the imaging modalities of choice to differentiate between Sawhney types.

Question 98: A 43-year-old teacher underwent left parotidectomy. Upon awakening from surgery, paralysis of the left lower lip was observed. This complication was most likely due to injury to which of the following?

A. Parotid duct
B. Facial nerve temporal branch
C. Facial nerve cervical branch (Correct Answer)
D. Facial nerve main trunk

Explanation: **Explanation:** The facial nerve (CN VII) is the most critical structure encountered during parotid surgery. It divides within the gland into five terminal branches: temporal, zygomatic, buccal, marginal mandibular, and cervical. **Why the Cervical Branch is Correct:** The **cervical branch** of the facial nerve descends into the neck and supplies the **platysma muscle**. In many individuals, the platysma is the primary muscle responsible for depressing the lower lip (along with the marginal mandibular branch). Injury to the cervical branch leads to a characteristic "pseudoparalysis" or weakness of the lower lip, particularly noticeable during speech or smiling, as the antagonistic pull of the upper lip muscles is unopposed. In the context of parotidectomy, this is a recognized postoperative complication. **Analysis of Incorrect Options:** * **Parotid duct:** This is a secretory structure (Stensen’s duct). Injury would lead to a salivary fistula or sialocele, not motor paralysis. * **Facial nerve temporal branch:** This branch supplies the frontalis and orbicularis oculi. Injury would result in the inability to wrinkle the forehead or close the eye tightly. * **Facial nerve main trunk:** Injury to the main trunk (proximal to the pes anserinus) would result in **complete ipsilateral facial paralysis** (Bell's-like palsy), affecting the forehead, eye, and mouth simultaneously. **NEET-PG High-Yield Pearls:** * **Most common nerve injured in parotidectomy:** Greater auricular nerve (leads to numbness over the ear lobe). * **Marginal Mandibular Nerve:** Often cited as the nerve causing lower lip drooping; however, in many surgical exams, the cervical branch is highlighted for its role via the platysma. * **Frey’s Syndrome:** A late complication of parotidectomy due to aberrant regeneration of auriculotemporal nerve fibers (parasympathetic to sympathetic). * **Landmark for Facial Nerve:** The **Tragal pointer** (the nerve is roughly 1 cm deep and slightly anterior/inferior to it).

Question 99: Which of the following is FALSE about a thyroglossal fistula?

A. It is a congenital remnant of the thyroglossal tract, typically presenting in the midline of the neck. (Correct Answer)
B. It often presents as a discharging sinus that is prone to recurrent infections.
C. Treatment involves the excision of the fistula and the entire thyroglossal tract up to the base of the tongue.
D. Surgical excision typically requires the removal of the middle third of the hyoid bone.

Explanation: ### Explanation **1. Why Option A is the Correct Answer (The False Statement):** A thyroglossal **fistula** is almost never congenital. While the thyroglossal **cyst** is a congenital remnant of the thyroglossal tract, a fistula typically develops **secondarily** due to the infection and spontaneous rupture of a cyst, or following inadequate surgical drainage (incisional biopsy). Because it has only one external opening, it is technically a **sinus**, though the term "fistula" is commonly used in clinical practice. **2. Analysis of Incorrect Options (True Statements):** * **Option B:** True. The fistula presents as a small opening in the midline of the neck, usually below the hyoid bone. It characteristically discharges mucus and is highly susceptible to recurrent bouts of infection. * **Option C & D:** True. These describe the **Sistrunk Operation**, the gold-standard treatment. Because the thyroglossal tract is intimately related to the hyoid bone (passing anterior, posterior, or through it), the **middle third of the hyoid bone** must be excised along with the entire tract up to the foramen caecum at the base of the tongue to prevent recurrence. **3. Clinical Pearls for NEET-PG:** * **Movement:** Both thyroglossal cysts and fistulae move upward on **protrusion of the tongue** (due to the attachment to the foramen caecum) and on **deglutition**. * **Location:** Most common site is **infrahyoid** (80%). * **Ectopic Thyroid:** Always perform an ultrasound to confirm the presence of a normal thyroid gland; in some cases, the "cyst" may be the patient's only functioning thyroid tissue. * **Malignancy:** The most common carcinoma arising in a thyroglossal remnant is **Papillary Carcinoma of the Thyroid**.

Question 100: A 65-year-old tobacco chewer presents with sublingual cancer involving the mandible. Commando surgery has been planned. Which of the following structures is NOT removed during a commando operation?

A. Involved mandible
B. Oral cancer
C. Accessory nerve (Correct Answer)
D. Neck lymph nodes

Explanation: ### Explanation **Commando Surgery** (Combined Mandibulectomy and Neck Dissection Operation) is a radical surgical procedure primarily performed for advanced oral cavity cancers that involve or are fixed to the mandible. **1. Why "Accessory Nerve" is the Correct Answer:** The term "Commando" traditionally refers to a **Radical Neck Dissection (RND)** combined with the excision of the primary oral lesion and a segment of the mandible. In a standard Radical Neck Dissection, three non-lymphatic structures are routinely sacrificed: the Internal Jugular Vein (IJV), the Sternocleidomastoid muscle (SCM), and the **Spinal Accessory Nerve (CN XI)**. However, in modern surgical practice, the trend has shifted toward **Modified Radical Neck Dissection (MRND)**, where the Spinal Accessory Nerve is specifically **preserved** to prevent "Shoulder Syndrome" (shoulder drop and pain due to trapezius paralysis). Therefore, in the context of this question, the Accessory Nerve is the structure intended to be spared whenever oncologically feasible, unlike the tumor and involved bone. **2. Analysis of Incorrect Options:** * **Oral Cancer (B) & Involved Mandible (A):** The core objective of Commando surgery is the "en-bloc" resection of the primary tumor along with the segment of the mandible it involves to ensure clear margins. * **Neck Lymph Nodes (D):** Neck dissection is an integral part of the procedure to address regional metastasis, which is common in advanced oral malignancies. **3. High-Yield Clinical Pearls for NEET-PG:** * **Etymology:** The name "Commando" was coined during WWII, comparing the aggressive, extensive nature of the surgery to the "Commando" raids of the era. * **Indication:** Specifically indicated when the tumor is fixed to the mandible or shows radiological evidence of bone invasion. * **Structures sacrificed in RND:** IJV, SCM, and Spinal Accessory Nerve. * **MRND Types:** * Type I: Preserves Accessory Nerve. * Type II: Preserves Accessory Nerve and IJV. * Type III (Functional): Preserves all three (Nerve, IJV, and SCM).

Practice by Chapter

Salivary Gland Diseases

Practice Questions

Thyroid Gland Disorders

Practice Questions

Parathyroid Gland Disorders

Practice Questions

Neck Masses Evaluation

Practice Questions

Oral Cavity Lesions

Practice Questions

Laryngeal Disorders

Practice Questions

Head and Neck Cancer

Practice Questions

Reconstructive Techniques in Head and Neck Surgery

Practice Questions

Surgical Management of Sleep Apnea

Practice Questions

Airway Management in Head and Neck Surgery

Practice Questions

Surgical Approaches to the Neck

Practice Questions

Neck Dissection Techniques

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free