Head and Neck Surgery — MCQs

A 34-year-old woman is admitted to the hospital with a large mass at her thyroid gland. Ultrasound examination reveals a benign tumor. Twenty-four hours following a partial thyroidectomy, in which the inferior thyroid artery was also ligated, the patient speaks with a hoarse voice and has difficulty in breathing on exertion. Which of the following nerves was most likely injured during the surgical procedure?

Q120Medium

A 80-year-old edentulous patient presents with a midline tumor of the lower jaw, involving the alveolar margin. What is the treatment of choice?

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 111: Which of the following statements regarding a branchial cyst is true?

A. Seen deep to the lower third of the sternocleidomastoid muscle.
B. The wall consists of lymphoid tissue. (Correct Answer)
C. Filled with keratinized fluid.
D. Typically presents at birth.

Explanation: **Explanation:** **1. Why Option B is Correct:** A branchial cyst is a remnant of the **second branchial cleft** (95% of cases). Histologically, the cyst is lined by stratified squamous epithelium (or sometimes respiratory epithelium) and is characteristically surrounded by a dense layer of **lymphoid tissue** containing germinal centers. This lymphoid component is a hallmark feature, often leading to the cyst enlarging rapidly during or after an upper respiratory tract infection. **2. Why the Other Options are Incorrect:** * **Option A:** Branchial cysts are typically located at the junction of the **upper third and middle third** of the anterior border of the sternocleidomastoid muscle. They are not found in the lower third. * **Option C:** The cyst is filled with a straw-colored, mucoid fluid that contains **cholesterol crystals** (giving it an opalescent appearance), not keratinized fluid. Keratinized fluid is more characteristic of dermoid cysts. * **Option D:** Although congenital in origin, they **rarely present at birth**. They typically manifest in late childhood or early adulthood (2nd or 3rd decade of life) when the lymphoid tissue undergoes hyperplasia or the cyst becomes infected. **Clinical Pearls for NEET-PG:** * **Most Common Site:** Anterior to the upper 1/3rd of the sternocleidomastoid, at the level of the hyoid bone. * **Diagnostic Feature:** Aspiration shows **cholesterol crystals** (shimmering appearance). * **Differential Diagnosis:** Must be differentiated from a "Cold Abscess" (tuberculous lymphadenitis) or a cystic hygroma. * **Treatment:** Complete surgical excision (Sistrunk procedure is for thyroglossal cysts, not branchial cysts). Be mindful of the internal carotid artery and jugular vein during surgery.

Question 112: Which of the following swellings is not located in the midline?

A. Thyroglossal cyst
B. Sublingual dermoid
C. Branchial cyst (Correct Answer)
D. Submental lymph node enlargement

Explanation: To approach midline neck swellings in surgery, it is essential to distinguish between structures derived from the midline (like the thyroid primordium) and those derived from the lateral branchial arches. ### **Explanation of the Correct Answer** **C. Branchial Cyst:** This is the correct answer because a branchial cyst is a **lateral neck swelling**. It typically arises from the remnants of the **second branchial cleft**. Clinically, it presents at the junction of the upper one-third and middle one-third of the anterior border of the **sternocleidomastoid muscle**. Because it originates from the branchial apparatus (which develops laterally), it is never found in the midline. ### **Analysis of Incorrect Options** * **A. Thyroglossal Cyst:** This is the most common midline developmental cyst. It occurs anywhere along the path 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**. * **B. Sublingual Dermoid:** These are sequestration dermoids found in the midline of the floor of the mouth (submental region). They can be suprahyoid and are strictly midline. * **D. Submental Lymph Node Enlargement:** The submental triangle is a midline space bounded by the anterior bellies of the digastric muscles and the hyoid bone. Enlargement of these nodes (due to infections or malignancy of the lower lip/floor of mouth) presents as a midline swelling. ### **High-Yield NEET-PG Pearls** * **Most common midline swelling:** Thyroglossal cyst. * **Most common lateral neck swelling:** Lymphadenopathy (inflammatory or metastatic). * **Branchial Cyst Fluid:** Classically contains **cholesterol crystals** (shimmering appearance). * **Movement on Deglutition:** Both Thyroglossal cysts and Thyroid swellings move with swallowing, but only the **Thyroglossal cyst moves with tongue protrusion**.

Question 113: Which statement is NOT true regarding carotid body tumors?

A. Unilateral
B. Surgical resection is the treatment
C. Non-chromaffin paraganglioma
D. None of the above (Correct Answer)

Explanation: **Explanation:** The correct answer is **D (None of the above)** because all the statements provided (A, B, and C) are clinically accurate descriptions of carotid body tumors (CBTs). 1. **Statement A (Unilateral):** While CBTs can be bilateral (especially in familial cases associated with SDH mutations), the **vast majority (approx. 90%) are sporadic and unilateral**. Therefore, describing them as unilateral is a true general characteristic. 2. **Statement B (Surgical resection is the treatment):** Surgical excision is the definitive treatment of choice. For larger tumors, preoperative embolization may be used to reduce vascularity. 3. **Statement C (Non-chromaffin paraganglioma):** CBTs arise from the extra-adrenal neural crest cells. Unlike the adrenal medulla, these cells do not stain with chromium salts (non-chromaffin) and usually do not secrete catecholamines. Since all statements are true, "None of the above" is the only logical choice for a "NOT true" question. **Clinical Pearls for NEET-PG:** * **Fontaine’s Sign:** The tumor is mobile horizontally but fixed vertically (due to its location within the carotid sheath). * **Lyre Sign:** On angiography, the tumor causes widening/splaying of the carotid bifurcation (displacement of internal and external carotid arteries). * **Origin:** It arises from the **chemoreceptors** located at the carotid bulb (sensitive to hypoxia and hypercapnia). * **Shamblin Classification:** Used to grade the tumor based on its involvement/encasement of the carotid vessels, which predicts surgical difficulty. * **Malignancy:** Only about 10% are malignant; malignancy is defined by lymph node or distant metastasis, not histology.

Question 114: What is the treatment of choice for pleomorphic adenoma?

A. Superficial parotidectomy (Correct Answer)
B. Radical parotidectomy
C. Enucleation
D. Radiotherapy

Explanation: **Explanation:** **Pleomorphic Adenoma** (Benign Mixed Tumor) is the most common salivary gland tumor, most frequently involving the superficial lobe of the parotid gland. **1. Why Superficial Parotidectomy is the Correct Choice:** The treatment of choice is **Superficial Parotidectomy** (removal of the superficial lobe with preservation of the facial nerve). This is because pleomorphic adenomas possess a "false capsule" with microscopic finger-like projections (pseudopods) that extend beyond the main tumor mass. A wide margin of healthy tissue is required to ensure these projections are removed, preventing recurrence. **2. Why Other Options are Incorrect:** * **Enucleation:** This involves "shelling out" the tumor. It is contraindicated because it inevitably leaves behind pseudopods or ruptures the capsule (seeding), leading to a high recurrence rate (up to 45%). * **Radical Parotidectomy:** This involves the sacrifice of the facial nerve. It is reserved for high-grade malignancies with nerve involvement, not for benign tumors like pleomorphic adenoma. * **Radiotherapy:** Pleomorphic adenoma is relatively radioresistant. Radiation is generally avoided due to the risk of malignant transformation (Carcinoma ex-pleomorphic adenoma). **Clinical Pearls for NEET-PG:** * **Most common site:** Tail of the parotid gland. * **Nerve Preservation:** The most important landmark to identify the facial nerve during surgery is the **Tragal Pointer**. * **Recurrence:** If a pleomorphic adenoma recurs, it often presents as multiple nodules (multicentric), making subsequent surgery difficult and increasing the risk of facial nerve injury. * **Frey’s Syndrome:** The most common late complication of superficial parotidectomy, diagnosed by the Minor’s Starch-Iodine test.

Question 115: During the surgical removal of a torus palatinus, a portion of the palatal bone was fractured. What would you expect to occur?

A. An opening into the nasal cavity (Correct Answer)
B. An opening into the maxillary antrum
C. A vertical fracture of the maxilla
D. A horizontal fracture of the maxilla

Explanation: ### Explanation **Correct Option: A. An opening into the nasal cavity** **Medical Concept:** The **torus palatinus** is a benign bony exostosis (hyperostosis) located at the midline of the hard palate. Anatomically, the hard palate is formed by the palatine processes of the maxillae and the horizontal plates of the palatine bones. This structure serves as both the floor of the nasal cavity and the roof of the oral cavity. Because the bone at the midline of the palate is often thin, surgical removal or accidental fracture during the excision of a torus palatinus frequently leads to a communication with the **nasal cavity**, potentially resulting in an oronasal fistula. **Analysis of Incorrect Options:** * **B. An opening into the maxillary antrum:** The maxillary sinus (antrum) is located laterally to the nasal cavity, above the molar and premolar teeth. A midline fracture of the palate involves the nasal floor, not the lateral maxillary walls. * **C & D. Vertical/Horizontal fracture of the maxilla:** These are major traumatic injuries (e.g., Le Fort fractures). Surgical removal of a localized bony outgrowth like a torus palatinus involves superficial bone work; while it may cause a localized perforation (fracture of the thin palatal shelf), it lacks the force required to cause a complete segmental or Le Fort-type maxillary fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Prevalence:** Torus palatinus is more common in females and usually appears in the 2nd or 3rd decade of life. * **Indications for Surgery:** Most are asymptomatic and require no treatment. Surgery is indicated only if it interferes with speech, causes recurrent mucosal ulceration, or prevents the stable fitting of a denture. * **Surgical Risk:** The most common complication during removal is **nasal perforation**. * **Torus Mandibularis:** This is a similar bony outgrowth usually found on the lingual aspect of the mandible, typically in the premolar region.

Question 116: Which of the following is true of a carotid body tumor?

A. It is a non-chromaffin paraganglioma.
B. It has a good prognosis.
C. It rarely metastasizes.
D. All of the above. (Correct Answer)

Explanation: A **Carotid Body Tumor (CBT)**, also known as a **Chemodectoma**, is a rare neoplasm arising from the chemoreceptor cells located at the bifurcation of the common carotid artery. ### **Detailed Explanation** * **Option A (Non-chromaffin paraganglioma):** Carotid bodies are derived from the neural crest. Unlike the adrenal medulla, these cells do not stain with chromium salts (non-chromaffin) and do not typically secrete catecholamines. They function as chemoreceptors sensitive to changes in arterial pH, $pCO_2$, and $pO_2$. * **Option B (Good Prognosis):** Most CBTs are slow-growing, painless, and benign. With modern surgical techniques and preoperative embolization, the prognosis is excellent, although there is a risk of cranial nerve injury (CN IX, X, XI, XII) during excision. * **Option C (Rarely metastasizes):** Only about 5–10% of carotid body tumors are malignant. Malignancy is defined by **clinically documented metastasis** to regional lymph nodes or distant organs (lungs/bones), rather than histological appearance. Since all three statements are accurate descriptions of the pathology, **Option D** is the correct answer. ### **High-Yield Clinical Pearls for NEET-PG** * **Fontaine’s Sign:** The tumor is vertically fixed but **horizontally mobile** (due to its location within the carotid sheath). * **Lyre’s Sign:** On angiography, there is a characteristic splaying/widening of the carotid bifurcation. * **Shamblin Classification:** Used to grade the tumor based on its involvement/encasement of the carotid vessels. * **Genetics:** Approximately 10–35% are familial (often autosomal dominant); these are more likely to be bilateral and are associated with **SDHD gene** mutations. * **Treatment of Choice:** Surgical excision, often preceded by preoperative embolization to reduce vascularity.

Question 117: All of the following are true about branchial cysts except?

A. They are commonly located in the anterior triangle of the neck. (Correct Answer)
B. They are lined by squamous epithelium.
C. They are remnants of a persistent branchial apparatus.
D. They may contain granulation tissue.

Explanation: **Explanation** Branchial cysts are congenital developmental anomalies arising from the persistent remnants of the **second branchial cleft** (95% of cases). **Why Option A is the Correct Answer (The False Statement):** While branchial cysts are technically in the "anterior triangle" by broad anatomical definition, the classic, high-yield description for exams is their specific relationship to the Sternocleidomastoid (SCM) muscle. They are located at the **junction of the upper 1/3rd and middle 1/3rd of the SCM, along its anterior border.** In clinical practice and NEET-PG questions, "anterior triangle" is often considered too vague or incorrect when compared to the specific landmark of the **anterior border of the SCM**. **Analysis of Other Options:** * **Option B:** Most branchial cysts are lined by **stratified squamous epithelium** (90%), though they can occasionally be lined by columnar epithelium if they originate deeper. * **Option C:** They are indeed remnants of the **branchial apparatus**, specifically the cervical sinus of His, which fails to involute during embryonic development. * **Option D:** If a branchial cyst becomes infected (a common presentation), the wall may develop **granulation tissue** and the lymphoid tissue in the wall may show germinal centers. **NEET-PG High-Yield Pearls:** * **Content:** They contain a characteristic "straw-colored" fluid rich in **cholesterol crystals**. * **Demographics:** Typically present in late childhood or early adulthood (20s-30s). * **Differential Diagnosis:** Must be distinguished from a **Carotid Body Tumor** (which is pulsatile and moves laterally but not vertically) and **Cystic Hygroma** (which transilluminates). * **Treatment:** Complete surgical excision (Sistrunk procedure is for Thyroglossal cysts, not branchial cysts).

Question 118: Access to the temporomandibular joint (TMJ) is typically achieved through which surgical approach?

A. Preauricular approach
B. Endaural approach
C. Submandibular incision
D. All of the above (Correct Answer)

Explanation: The surgical management of the temporomandibular joint (TMJ) requires versatile access depending on the pathology (e.g., ankylosis, condylar fractures, or internal derangement). The correct answer is **"All of the above"** because different clinical scenarios dictate different surgical corridors. ### **Explanation of Approaches:** 1. **Preauricular Approach (Option A):** This is the **most common** and standard approach for TMJ surgery. The incision is made in the skin fold immediately in front of the pinna. It provides excellent exposure of the glenoid fossa, articular disc, and the superior aspect of the condyle while allowing the scar to be hidden in natural skin creases. 2. **Endaural Approach (Option B):** This is a modification of the preauricular incision where the incision extends into the external auditory canal. It offers a more direct view of the posterior aspect of the joint and results in a superior cosmetic outcome as the scar is largely internal. 3. **Submandibular (Risdon) Incision (Option C):** While primarily used for the ramus and body of the mandible, it is frequently used in TMJ surgery (especially for ankylosis or low condylar fractures) to provide access to the inferior aspect of the joint and to facilitate the placement of hardware or gap arthroplasty. ### **Clinical Pearls for NEET-PG:** * **Facial Nerve Protection:** The most critical structure at risk during TMJ surgery is the **Temporal (Frontal) branch of the Facial Nerve**. Surgeons must remain deep to the superficial layer of the deep temporal fascia to avoid injury. * **Al-Kayat and Bramley Incision:** A high-yield modification of the preauricular approach that provides wider exposure for complex reconstructions. * **Post-operative Complication:** Frey’s Syndrome (auriculotemporal nerve injury) is a rare but possible complication of these approaches, though more commonly associated with parotid surgery.

Question 119: A 34-year-old woman is admitted to the hospital with a large mass at her thyroid gland. Ultrasound examination reveals a benign tumor. Twenty-four hours following a partial thyroidectomy, in which the inferior thyroid artery was also ligated, the patient speaks with a hoarse voice and has difficulty in breathing on exertion. Which of the following nerves was most likely injured during the surgical procedure?

A. Internal branch of superior laryngeal
B. Ansa cervicalis
C. Ansa subclavia
D. Recurrent laryngeal (Correct Answer)

Explanation: ### Explanation The patient’s symptoms of **hoarseness** and **exertional dyspnea** following a partial thyroidectomy indicate vocal cord dysfunction, most likely due to injury of the **Recurrent Laryngeal Nerve (RLN)**. **1. Why the Recurrent Laryngeal Nerve is correct:** The RLN provides motor innervation to all intrinsic muscles of the larynx except the cricothyroid. It also provides sensory innervation to the larynx below the vocal folds. Anatomically, the RLN is in close proximity to the **inferior thyroid artery**, often crossing it or running posterior to it. Ligation of this artery during thyroid surgery is a high-risk step where the RLN can be accidentally clamped, stretched, or transected. Unilateral injury leads to hoarseness, while bilateral injury can cause airway obstruction (breathing difficulty) as the vocal cords remain in a paramedian position. **2. Why the other options are incorrect:** * **Internal branch of superior laryngeal nerve:** This nerve is purely sensory to the larynx above the vocal folds. Injury results in loss of the cough reflex (increasing aspiration risk) but does not cause hoarseness or breathing difficulty. * **Ansa cervicalis:** This nerve loop (C1-C3) innervates the infrahyoid (strap) muscles. Injury does not affect the voice or airway significantly. * **Ansa subclavia:** This is a nerve loop connecting the middle and inferior cervical sympathetic ganglia. Injury would lead to sympathetic deficits (like Horner’s syndrome) rather than laryngeal symptoms. **3. NEET-PG High-Yield Pearls:** * **Superior Thyroid Artery:** Closely related to the **External branch of the Superior Laryngeal Nerve** (EBSLN). Injury to EBSLN causes loss of high-pitched voice (cricothyroid paralysis). * **Inferior Thyroid Artery:** Closely related to the **Recurrent Laryngeal Nerve**. * **Surgical Tip:** To avoid nerve injury, the Superior Thyroid Artery should be ligated **close to the gland**, while the Inferior Thyroid Artery should be ligated **far from the gland**. * **Most common nerve injured** in thyroid surgery: External branch of the Superior Laryngeal Nerve (often underdiagnosed).

Question 120: A 80-year-old edentulous patient presents with a midline tumor of the lower jaw, involving the alveolar margin. What is the treatment of choice?

A. Hemi-mandibulectomy
B. Commando operation
C. Segmental mandibulectomy (Correct Answer)
D. Marginal mandibulectomy

Explanation: ### Explanation The management of mandibular tumors depends on the site of the tumor and the quality of the bone. In this case, the correct choice is **Segmental mandibulectomy** due to the patient’s age and dental status. **Why Segmental Mandibulectomy is correct:** In an **80-year-old edentulous patient**, the mandible undergoes significant physiological resorption. The vertical height of the bone is greatly reduced, and the **inferior alveolar artery** (the primary blood supply in younger adults) often becomes obliterated. In such patients, the mandible relies on the periosteal blood supply. A marginal mandibulectomy (removing only the upper border) in a thin, resorbed edentulous jaw leaves behind a very thin rim of bone that is highly prone to **pathological fractures** and has poor healing potential. Therefore, a full-thickness (segmental) resection is required to ensure oncological clearance and avoid post-operative complications. **Why other options are incorrect:** * **Marginal mandibulectomy:** This is preferred in dentate patients with adequate mandibular height where at least 1 cm of the lower border can be preserved. In an edentulous patient, there is insufficient bone height to perform this safely. * **Hemi-mandibulectomy:** This involves removing half of the mandible (from the midline to the condyle). Since the tumor is midline, a segmental resection of the involved area is sufficient and less morbid than removing the entire half. * **Commando operation:** (Composite Resection) This involves glossectomy, neck dissection, and mandibulectomy. It is indicated for advanced tumors involving the tongue and neck nodes, not specifically for an isolated midline jaw tumor. **Clinical Pearls for NEET-PG:** * **Blood supply shift:** In young/dentate patients, the mandible is supplied by the **inferior alveolar artery**. In elderly/edentulous patients, it is supplied by the **periosteal vessels** (branches of the facial artery). * **Rule of thumb:** If the tumor is within 1 cm of the bone or involves the periosteum, marginal mandibulectomy is considered. If it invades the marrow or the bone is resorbed (edentulous), segmental resection is mandatory.

Practice by Chapter

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