Head and Neck Surgery Practice Questions

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

The wall consists of lymphoid tissue.. **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.

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

Branchial cyst. 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**.

Q: Which statement is NOT true regarding carotid body tumors?

None of the above. **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.

Q: What is the treatment of choice for pleomorphic adenoma?

Superficial parotidectomy. **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.

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

All of the above.. 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.

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

All of the above. 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 1

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

Accepted Answer

The wall consists of lymphoid tissue.

Answer

Seen deep to the lower third of the sternocleidomastoid muscle.

Answer

Filled with keratinized fluid.

Answer

Typically presents at birth.

Question 2

Which of the following swellings is not located in the midline?

Accepted Answer

Branchial cyst

Answer

Thyroglossal cyst

Answer

Sublingual dermoid

Answer

Submental lymph node enlargement

Question 3

Which statement is NOT true regarding carotid body tumors?

Accepted Answer

None of the above

Answer

Unilateral

Answer

Surgical resection is the treatment

Answer

Non-chromaffin paraganglioma

Question 4

What is the treatment of choice for pleomorphic adenoma?

Accepted Answer

Superficial parotidectomy

Answer

Radical parotidectomy

Answer

Enucleation

Answer

Radiotherapy

Question 5

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

Accepted Answer

An opening into the nasal cavity

Answer

An opening into the maxillary antrum

Answer

A vertical fracture of the maxilla

Answer

A horizontal fracture of the maxilla

Question 6

Which of the following is true of a carotid body tumor?

Accepted Answer

All of the above.

Answer

It is a non-chromaffin paraganglioma.

Answer

It has a good prognosis.

Answer

It rarely metastasizes.

Question 7

All of the following are true about branchial cysts except?

Accepted Answer

They are commonly located in the anterior triangle of the neck.

Answer

They are lined by squamous epithelium.

Answer

They are remnants of a persistent branchial apparatus.

Answer

They may contain granulation tissue.

Question 8

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

Accepted Answer

All of the above

Answer

Preauricular approach

Answer

Endaural approach

Answer

Submandibular incision

Question 9

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?

Accepted Answer

Recurrent laryngeal

Answer

Internal branch of superior laryngeal

Answer

Ansa cervicalis

Answer

Ansa subclavia

Question 10

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?

Accepted Answer

Segmental mandibulectomy

Answer

Hemi-mandibulectomy

Answer

Commando operation

Answer

Marginal mandibulectomy

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?