Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 121: Which structure is preserved during modified radical neck dissection?

A. Phrenic nerve
B. Submandibular gland
C. Sternocleidomastoid muscle (Correct Answer)
D. Thoracic duct

Explanation: **Explanation:** The classification of neck dissections is a high-yield topic in surgery. To understand the correct answer, one must differentiate between a **Radical Neck Dissection (RND)** and a **Modified Radical Neck Dissection (MRND)**. **1. Why Option C is Correct:** In a **Radical Neck Dissection (RND)**, all lymph nodes from levels I-V are removed along with three non-lymphatic structures: the **Sternocleidomastoid (SCM) muscle**, the **Internal Jugular Vein (IJV)**, and the **Spinal Accessory Nerve (SAN)**. A **Modified Radical Neck Dissection (MRND)** involves the same lymph node clearance but **preserves** one or more of these three non-lymphatic structures. Therefore, the SCM is a structure specifically preserved in MRND (Types II and III). **2. Analysis of Incorrect Options:** * **Phrenic Nerve (A):** This is not part of the standard RND template; it lies deep to the prevertebral fascia and is routinely preserved in both RND and MRND to avoid diaphragmatic palsy. * **Submandibular Gland (B):** This is routinely removed in both RND and MRND as part of the Level Ib lymph node clearance. * **Thoracic Duct (D):** This is always preserved unless it is accidentally injured or involved by a tumor (usually on the left side). It is not one of the three defining structures that differentiate RND from MRND. **Clinical Pearls for NEET-PG:** * **MRND Type I:** Preserves the Spinal Accessory Nerve. * **MRND Type II:** Preserves SAN and Internal Jugular Vein. * **MRND Type III (Functional Neck Dissection):** Preserves all three (SAN, IJV, and SCM). * **Selective Neck Dissection:** Only specific lymph node levels are removed (e.g., Supraomohyoid dissection for oral cavity cancers).

Question 122: Which of the following statements regarding thyroglossal cysts is not true?

A. 80% are found in juxtaposition to the hyoid bone
B. Heterotopic thyroid tissue is present in 20% of cases
C. Rarely can contain foci of follicular carcinoma (Correct Answer)
D. The treatment of choice is Sistrunk operation

Explanation: ### Explanation **1. Why Option C is the Correct (False) Statement:** While malignancy in a thyroglossal cyst is rare (occurring in <1% of cases), the most common histological type is **Papillary Thyroid Carcinoma** (>80%), not follicular carcinoma. Follicular carcinoma is exceptionally rare in this location because the embryonic thyroid primordium lacks the environment typically required for follicular neoplastic transformation. **2. Analysis of Other Options:** * **Option A (True):** The hyoid bone is the most common site. Approximately 80% of cysts are found in juxtaposition to the hyoid (subhyoid being the most frequent, followed by suprahyoid and prehyoid). * **Option B (True):** Heterotopic thyroid tissue (normal thyroid follicles) is found in the wall of the cyst in about 20% of cases. This is a remnant of the descent of the thyroid gland from the foramen caecum. * **Option D (True):** The **Sistrunk Operation** is the gold standard treatment. It involves the excision of the cyst, the entire tract, and the **central portion of the hyoid bone** up to the foramen caecum to minimize the risk of recurrence (recurrence rate drops from ~50% to <5%). **Clinical Pearls for NEET-PG:** * **Embryology:** Arises from a persistent thyroglossal duct (remnant of the descent of the thyroid diverticulum). * **Clinical Sign:** It is a midline swelling that **moves upwards on protrusion of the tongue** (due to its attachment to the hyoid bone and foramen caecum). * **Differential Diagnosis:** Sublingual dermoid (does not move with tongue protrusion) and ectopic thyroid (ensure a normal thyroid gland is present before excision). * **Investigation of Choice:** Ultrasound is the initial investigation to confirm the cyst and verify the presence of a normal thyroid gland in the neck.

Question 123: Weber Ferguson incision is used for the surgical management of which cancer?

A. Breast cancer
B. Hard palate cancer (Correct Answer)
C. Thyroid cancer
D. Cancer of the penis

Explanation: **Explanation:** The **Weber-Ferguson incision** is the standard surgical approach used for **Maxillectomy**. It provides excellent exposure to the midface, including the maxilla, paranasal sinuses, and the **hard palate**. **Why the Correct Answer is Right:** Cancer of the hard palate often requires a partial or total maxillectomy to achieve clear oncological margins. The Weber-Ferguson incision involves an infraorbital component and a midline lip-split (cheilotomy), allowing the surgeon to reflect a large cheek flap. This provides the necessary visualization to resect the bony structures of the upper jaw and palate. **Why the Incorrect Options are Wrong:** * **Breast cancer:** Surgical management typically involves a periareolar, elliptical (Stewart), or transverse (Orr) incision for mastectomy. * **Thyroid cancer:** The standard approach is the **Kocher’s transverse collar incision**, made approximately 2 cm above the sternal notch. * **Cancer of the penis:** Surgical management (Partial or Total Penectomy) involves circular or elliptical incisions around the base of the shaft or the lesion; it does not involve facial incisions. **High-Yield Clinical Pearls for NEET-PG:** * **Dieffenbach Extension:** An extension of the Weber-Ferguson incision towards the temple to provide better access to the zygomatic bone. * **Lynch Extension:** An extension towards the medial canthus/bridge of the nose for access to the ethmoid sinuses. * **Complication:** A common post-operative concern with this incision is ectropion (eversion of the lower eyelid) or persistent facial edema. * **Alternative:** For smaller palatal lesions, an intra-oral approach may be used, but for malignant tumors, Weber-Ferguson remains the gold standard for exposure.

Question 124: All of the following are anatomical markers for the localization of the facial nerve during parotid surgery, except?

A. Posterior belly of Digastric
B. Mastoid process
C. Inferior belly of omohyoid (Correct Answer)
D. Bony external auditory meatus

Explanation: **Explanation:** The localization of the facial nerve is the most critical step in parotidectomy to avoid iatrogenic injury. The facial nerve exits the skull via the **stylomastoid foramen** and enters the parotid gland, where it divides into its terminal branches. **Why Option C is the correct answer:** The **inferior belly of the omohyoid** is located in the lower part of the neck (posterior triangle), crossing the internal jugular vein. It is a landmark for level III and IV neck dissections but has no anatomical proximity to the parotid gland or the facial nerve trunk. **Evaluation of other options (Anatomical Landmarks):** * **Posterior belly of Digastric (Option A):** The facial nerve trunk lies just superior to the upper border of this muscle. It is a highly reliable landmark. * **Mastoid process (Option B):** The nerve exits the stylomastoid foramen, which is located medial to the mastoid process. Palpating the mastoid helps orient the surgeon to the depth of the nerve. * **Bony external auditory meatus (Option C):** The nerve is located approximately 1 cm deep and slightly anterior-inferior to the **"Tragal Pointer"** (the deep extension of the tragal cartilage). The tympanomastoid fissure, located between the mastoid and the bony meatus, leads directly to the stylomastoid foramen. **High-Yield Clinical Pearls for NEET-PG:** * **Tragal Pointer:** The most commonly used landmark; the nerve lies 1 cm deep and slightly anterior-inferior to it. * **Tympanomastoid Fissure:** Considered the most precise landmark; the nerve is found 6–8 mm deep to this fissure. * **Retrograde Identification:** If the main trunk cannot be found, surgeons identify a peripheral branch (e.g., buccal) and trace it back to the pes anserinus. * **Styloid Process:** The nerve lies lateral to the styloid process.

Question 125: What is a potential complication of a biopsy taken for scalene lymph nodes?

A. Injury to the phrenic nerve
B. Injury to the vagus nerve
C. Injury to the apex of the lung (Correct Answer)
D. Injury to the trachea

Explanation: **Explanation:** The scalene lymph nodes (also known as the **Daniels’ node**) are located within the supraclavicular fat pad, resting on the scalenus anterior muscle. A scalene node biopsy is historically used to diagnose intrathoracic diseases like sarcoidosis or bronchogenic carcinoma. **Why the Correct Answer is Right:** The **apex of the lung** (covered by the cervical pleura or Sibson’s fascia) extends approximately 2.5 to 4 cm above the level of the first rib, deep to the scalene fat pad. During a biopsy, deep dissection or accidental penetration of the suprapleural membrane can lead to an **iatrogenic pneumothorax**. This is considered the most significant and common serious risk associated with the procedure due to the close anatomical proximity of the pleura to the scalene nodes. **Analysis of Incorrect Options:** * **A. Injury to the phrenic nerve:** While the phrenic nerve lies directly on the anterior surface of the scalenus anterior muscle, it is usually protected by the prevertebral fascia. While injury is possible (causing diaphragmatic palsy), it is less frequently cited as the primary complication compared to pleural injury in standard surgical texts. * **B. Injury to the vagus nerve:** The vagus nerve descends within the carotid sheath, medial to the scalene nodes. It is generally not at risk during a superficial supraclavicular dissection. * **C. Injury to the trachea:** The trachea is a midline structure, far medial to the lateral neck compartment where the scalene nodes are located. **NEET-PG High-Yield Pearls:** * **Daniels’ Node:** Specifically refers to the lymph nodes resting on the scalenus anterior muscle. * **Thoracic Duct:** On the **left side**, injury to the thoracic duct is a major risk, potentially leading to a chylous fistula. * **Horner’s Syndrome:** Can occur if the cervical sympathetic chain is injured during deep dissection. * **Virchow’s Node:** A specific enlarged left supraclavicular node (Troisier’s sign) indicating abdominal malignancy (e.g., gastric cancer).

Question 126: What is the best radiographic view for visualizing the mandible?

A. Anteroposterior view
B. Lateral view
C. Oblique view
D. Orthopantomogram (Correct Answer)

Explanation: **Explanation:** The **Orthopantomogram (OPG)**, also known as a panoramic radiograph, is the gold standard and best initial screening tool for visualizing the mandible. **Why OPG is the Correct Answer:** The OPG provides a continuous, curved, two-dimensional panoramic view of the entire mandible, including the body, symphysis, angles, rami, and both condyles. It is particularly superior because it eliminates the superimposition of the cervical spine and the contralateral side of the jaw, which often obscures details in standard plain films. It allows for the assessment of multiple fracture sites (as mandible fractures are often multiple) and the relationship of teeth to the fracture line. **Analysis of Incorrect Options:** * **Anteroposterior (AP) View:** This view suffers from significant superimposition of the base of the skull and the cervical spine, making it difficult to visualize the mandibular body and symphysis clearly. * **Lateral View:** A true lateral view results in the overlap of the right and left halves of the mandible, rendering it nearly useless for diagnostic purposes unless taken as a "Lateral Oblique." * **Oblique View:** While the Lateral Oblique (Body or Ramus) view can help visualize specific segments, it does not provide a comprehensive view of the entire mandibular arch in a single film like the OPG. **Clinical Pearls for NEET-PG:** * **Gold Standard for Trauma:** While OPG is the best *radiographic* view, **NCCT (Non-Contrast CT) with 3D reconstruction** is the overall gold standard for complex maxillofacial trauma. * **Towne’s View:** Best for visualizing the **mandibular condyles** and the subcondylar region. * **Water’s View:** Best for visualizing the **maxilla, maxillary sinuses, and orbital floor**. * **Ring Bone Principle:** The mandible acts like a ring; if you see one fracture, always look for a second (often contralateral) fracture.

Question 127: A 36-year-old man developed neck and left arm pain. He noted paresthesias in the left index and long fingers. He was found to have weakness of the left triceps muscle and a diminished left triceps jerk. His left-sided disc herniation is most likely to be at what level?

A. C3-C4
B. C4-C5
C. C5-C6
D. C6-C7 (Correct Answer)

Explanation: **Explanation:** The clinical presentation describes a **C7 radiculopathy**, which is most commonly caused by a posterolateral disc herniation at the **C6-C7 level**. In the cervical spine, the nerve root exits *above* the pedicle of the corresponding vertebra (e.g., the C7 nerve root exits through the C6-C7 intervertebral foramen). **Why C6-C7 is correct:** The C7 nerve root is responsible for: * **Motor:** Extension of the elbow (Triceps muscle) and wrist flexion. * **Reflex:** The Triceps jerk. * **Sensory:** Sensation to the middle finger (long finger) and often the index finger. The patient’s symptoms—triceps weakness, diminished triceps reflex, and paresthesia in the index/long fingers—perfectly align with C7 involvement. **Why other options are incorrect:** * **C3-C4 (C4 root):** Results in sensory loss at the base of the neck and top of the shoulder; no major limb muscle weakness or reflex changes. * **C4-C5 (C5 root):** Causes weakness in the Deltoid and Biceps, sensory loss over the lateral arm, and a diminished Biceps reflex. * **C5-C6 (C6 root):** Causes weakness in the Biceps and Brachioradialis (wrist extensors), sensory loss in the thumb and radial side of the forearm, and a diminished Brachioradialis reflex. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Level:** C6-C7 (C7 root) is the most frequent site of cervical disc herniation, followed by C5-C6 (C6 root). * **The "Rule of Fingers":** * C6 = Thumb ("6" looks like a 'b' for Biceps/Brachioradialis). * C7 = Middle finger (The "7" looks like a pointing finger). * C8 = Ring and Little fingers. * **Spurling’s Test:** A high-yield physical exam maneuver where neck extension and lateral rotation toward the affected side reproduce radicular pain.

Question 128: 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 or involving the **deep lobe** of the parotid gland. The parotid gland is divided into superficial and deep lobes by the plane of the facial nerve. While most pleomorphic adenomas occur in the superficial lobe, those in the deep lobe expand through the stylomandibular tunnel, presenting as a parapharyngeal mass that pushes the tonsil medially (often called a "dumbbell-shaped" 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** (lateral to the facial nerve). It would not address a tumor causing tonsillar displacement. * **Lumpectomy/Enucleation:** These are strictly contraindicated for pleomorphic adenoma. This tumor has a "false capsule" with microscopic finger-like projections (pseudopods). Simple enucleation leaves these projections behind, leading to a very high rate of local recurrence and potential seeding. **3. Clinical Pearls for NEET-PG:** * **Most common site:** Superficial lobe (80%). * **Most common parotid tumor:** Pleomorphic adenoma (Benign Mixed Tumor). * **Nerve preservation:** The facial nerve is the most important structure to identify during surgery. The **Tragal pointer** and the **posterior belly of the digastric muscle** are key anatomical landmarks used to locate the nerve trunk. * **Malignant transformation:** If left untreated, it can transform into *Carcinoma ex-pleomorphic adenoma* (risk increases with duration).

Question 129: Premature filling of veins is a manifestation in cerebral angiography of which condition?

A. Trauma
B. Brain tumor
C. Arteriovenous malformation (Correct Answer)
D. Arterial occlusion

Explanation: ### Explanation **Correct Answer: C. Arteriovenous malformation (AVM)** **Underlying Concept:** In a normal physiological state, blood travels from arteries to capillaries and then to veins. This transition creates a "capillary delay," meaning veins visualize on an angiogram several seconds after the arterial phase. In an **Arteriovenous Malformation (AVM)**, there is a direct communication between arteries and veins through a "nidus," bypassing the high-resistance capillary bed. This **shunting** results in rapid, high-pressure blood flow directly into the venous system. Consequently, veins appear prematurely on angiography (often simultaneously with the arteries), which is a pathognomonic sign of AVM. **Analysis of Incorrect Options:** * **A. Trauma:** While trauma can cause vascular injuries like dissections or hematomas, it typically results in extravasation of contrast or vessel narrowing, not a systematic premature venous filling. * **B. Brain tumor:** Highly vascular tumors (like glioblastoma) may show increased vascularity or "tumor blush," but they do not typically demonstrate the rapid, direct arteriovenous shunting seen in AVMs. * **D. Arterial occlusion:** This leads to a **delay** or complete absence of contrast distal to the blockage, the exact opposite of premature filling. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA) is the gold standard for diagnosing and mapping AVMs. * **Classic Angiographic Triad for AVM:** 1. Dilated feeding arteries. 2. A "nidus" (tangle of vessels). 3. **Early draining veins** (Premature filling). * **Clinical Presentation:** The most common presentations are intracranial hemorrhage (ICH) or new-onset seizures in a young adult. * **Spetzler-Martin Grade:** Used to assess the surgical risk of AVMs based on size, eloquence of adjacent brain tissue, and venous drainage pattern.

Question 130: A secretory sinus in the neck moves upon deglutition. What is the most likely diagnosis?

A. Branchial sinus
B. Pilonidal cyst
C. Thyroglossal fistula (Correct Answer)
D. Sublingual dermoid cyst

Explanation: ### Explanation **Correct Answer: C. Thyroglossal fistula** The key clinical finding in this question is the **movement of the sinus upon deglutition (swallowing)**. **1. Why Thyroglossal Fistula is Correct:** A thyroglossal fistula (or cyst) is a remnant of the thyroglossal duct, which marks the descent of the thyroid gland from the foramen caecum to its adult position. The duct is intimately associated with the **hyoid bone**. Because the hyoid bone is attached to the larynx via the thyrohyoid membrane, it moves upward during swallowing. Consequently, any structure attached to the thyroglossal tract—whether a cyst or a fistula—will move upward upon deglutition. *Note:* If the question mentioned movement upon **protrusion of the tongue**, it would also point toward a thyroglossal remnant, as the tract is attached to the base of the tongue. **2. Why Other Options are Incorrect:** * **A. Branchial sinus:** These are typically located at the anterior border of the sternocleidomastoid muscle (usually the lower third). They do not have an anatomical connection to the hyoid or larynx and thus **do not move** with swallowing. * **B. Pilonidal cyst:** This is a condition occurring in the sacrococcygeal region; it is not found in the neck. * **C. Sublingual dermoid cyst:** While these occur in the midline of the floor of the mouth/neck, they are not attached to the hyoid bone or the thyroglossal tract and do not move with swallowing or tongue protrusion. **3. High-Yield Clinical Pearls for NEET-PG:** * **Sistrunk Operation:** The definitive surgical treatment for thyroglossal remnants. It involves the excision of the cyst/fistula, the entire tract, and the **central part of the hyoid bone** to prevent recurrence. * **Location:** Thyroglossal cysts are most commonly **subhyoid** (midline). * **Acquired Nature:** A thyroglossal fistula is rarely congenital; it usually follows the infection or inadequate excision of a thyroglossal cyst.

Practice by Chapter

Salivary Gland Diseases

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Thyroid Gland Disorders

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Parathyroid Gland Disorders

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Neck Masses Evaluation

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Oral Cavity Lesions

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Laryngeal Disorders

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Head and Neck Cancer

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Reconstructive Techniques in Head and Neck Surgery

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Surgical Management of Sleep Apnea

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Airway Management in Head and Neck Surgery

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Surgical Approaches to the Neck

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Neck Dissection Techniques

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