Head and Neck Surgery — MCQs

A 40-year-old woman presents with a painless mass anterior to her left ear. The mass had been slowly enlarging over the past year. The mass is firm and nontender. Computed tomography and magnetic resonance imaging reveal a well-circumscribed, homogeneous mass within the left parotid gland. Biopsy reveals anastomosing strands of stellate and fusiform epithelial cells embedded in a myxoid stroma. Which of the following is a characteristic of this lesion?

Q145Medium

A 62-year-old man undergoes excision of a cylindroma of the submandibular gland. He is most likely to have an injury to which of the following nerves?

Q146Medium

Carcinoma of the lip is characterized by the following, except:

Q147Medium

In Submandibular gland surgery, which nerve is least likely to be injured?

Q148Easy

Carcinoma of the tongue most commonly occurs at which location?

Q149Easy

Which muscle is resected in a classical neck dissection?

Q150Medium

Which of the following statements regarding symptomatic thyroglossal duct cysts is true?

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 141: A 4-year-old boy is brought to the physician's office for evaluation of small stature. A thyroid scan shows no uptake in the neck. Which structure is embryologically related to the thyroid gland and should be carefully evaluated?

A. Foramen cecum (Correct Answer)
B. Foramen ovale
C. Foramen rotundum
D. Foramen spinosum

Explanation: ### Explanation **1. Why Foramen Cecum is Correct:** The thyroid gland begins its development as an endodermal proliferation at the floor of the pharynx, specifically at a point between the tuberculum impar and the copula. This site of origin is marked in the adult tongue by the **foramen cecum**. During the 4th week of gestation, the thyroid primordium descends from the foramen cecum to its final position in the neck via the **thyroglossal duct**. In this clinical scenario, the lack of uptake in the neck suggests **thyroid dysgenesis** (likely an ectopic thyroid). The most common site for an ectopic thyroid is the lingual region, located at the base of the tongue near the foramen cecum. **2. Why Other Options are Incorrect:** * **B, C, and D (Foramen Ovale, Rotundum, and Spinosum):** These are openings in the **greater wing of the sphenoid bone** at the base of the skull. They transmit cranial nerves (V2, V3) and vessels (middle meningeal artery). They are derived from the neurocranium and have no embryological or anatomical relationship with the descent of the thyroid gland or the pharyngeal arches. **3. NEET-PG High-Yield Pearls:** * **Ectopic Thyroid:** The most common location is the **Lingual Thyroid** (at the foramen cecum). If a lingual thyroid is present, it is often the *only* functioning thyroid tissue in 70% of cases; surgical removal without replacement leads to permanent hypothyroidism. * **Thyroglossal Duct Cyst:** Occurs due to failure of the duct to obliterate. It is typically a midline neck swelling that **moves upward on protrusion of the tongue** (due to its attachment to the hyoid bone and foramen cecum). * **Pyramidal Lobe:** A normal anatomical variant representing a persistent distal portion of the thyroglossal duct.

Question 142: In the classical radical neck dissection (Crile), which structure is NOT removed?

A. Cervical group of lymph nodes
B. Sternocleidomastoid muscle
C. Internal jugular vein
D. None of the above (Correct Answer)

Explanation: ### Explanation The **Classical Radical Neck Dissection (RND)**, originally described by George Crile in 1906, is the gold standard surgical procedure for managing cervical lymph node metastasis. The fundamental principle of RND is the en-bloc removal of all lymphatic tissues from one side of the neck. **Why "None of the above" is correct:** In a Classical RND, three specific non-lymphatic structures are routinely sacrificed to ensure complete oncological clearance of the associated lymph nodes. These are: 1. **Sternocleidomastoid muscle (SCM)** 2. **Internal Jugular Vein (IJV)** 3. **Spinal Accessory Nerve (SAN - Cranial Nerve XI)** Since options A, B, and C (Cervical lymph nodes, SCM, and IJV) are all standard components removed during the procedure, none of them are "not removed." **Analysis of Options:** * **Cervical group of lymph nodes:** RND removes lymph node levels I through V. This is the primary goal of the surgery. * **Sternocleidomastoid muscle:** Removed to gain access to the deep cervical nodes and ensure clearance of the lymphatic channels piercing the muscle. * **Internal jugular vein:** Removed because the deep cervical lymph nodes are intimately attached to its adventitia. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Radical Neck Dissection (MRND):** This involves the removal of lymph node levels I-V but **preserves** one or more non-lymphatic structures (SAN, IJV, or SCM). * *Type I:* Preserves Spinal Accessory Nerve. * *Type II:* Preserves SAN and IJV. * *Type III (Functional Neck Dissection):* Preserves all three (SAN, IJV, and SCM). * **Extended Neck Dissection:** Removal of additional lymph node groups (e.g., Level VI) or non-lymphatic structures (e.g., Carotid artery, Hypoglossal nerve) not included in the classical RND. * **Most common complication of RND:** Shoulder dysfunction/droop (due to sacrifice of the Spinal Accessory Nerve).

Question 143: Which of the following statements is true regarding salivary glands?

A. There are more than 400 minor salivary glands.
B. 90% of all parotid tumors are malignant. (Correct Answer)
C. 90% of minor salivary tumors are malignant.
D. Superficial parotidectomy is performed for parotid tumors.

Explanation: ### Explanation **Correct Answer: B. 90% of all parotid tumors are malignant.** In salivary gland pathology, there is an inverse relationship between the size of the gland and the likelihood of malignancy (the **"Rule of 80s"** or similar proportions). The parotid gland is the largest salivary gland and the most common site for tumors (80%). However, approximately **80-90% of parotid tumors are benign** (most commonly Pleomorphic Adenoma). Therefore, the statement that 90% are malignant is technically the "keyed" answer in many traditional question banks, though clinically, it is the **inverse** that is true. *Note: In many standard textbooks (Bailey & Love), 80-90% of parotid tumors are BENIGN. If this question appears in NEET-PG with this specific key, it follows an older or specific examiner logic; however, the clinical fact is that malignancy risk increases as gland size decreases.* **Analysis of Other Options:** * **A. Minor Salivary Glands:** There are actually **600 to 1,000** minor salivary glands distributed throughout the oral cavity and oropharynx, not just 400. * **C. Minor Salivary Tumors:** Approximately **50%** of minor salivary gland tumors are malignant. While they have a higher malignancy rate than the parotid, it is not as high as 90%. * **D. Superficial Parotidectomy:** While common for tumors in the superficial lobe, the surgical approach depends on the tumor's location and nature. If a tumor involves the deep lobe or is highly invasive, a total parotidectomy is required. **High-Yield Clinical Pearls for NEET-PG:** * **Most common benign tumor:** Pleomorphic Adenoma (all glands). * **Most common malignant tumor:** Mucoepidermoid Carcinoma (overall). * **Adenoid Cystic Carcinoma:** Most common malignancy in the submandibular and minor salivary glands; known for **perineural invasion**. * **Warthin’s Tumor:** Found almost exclusively in the parotid; associated with smoking and often bilateral/multicentric. * **Frey’s Syndrome:** A complication of parotidectomy (gustatory sweating) diagnosed by the **Minor’s Starch-Iodine test**.

Question 144: A 40-year-old woman presents with a painless mass anterior to her left ear. The mass had been slowly enlarging over the past year. The mass is firm and nontender. Computed tomography and magnetic resonance imaging reveal a well-circumscribed, homogeneous mass within the left parotid gland. Biopsy reveals anastomosing strands of stellate and fusiform epithelial cells embedded in a myxoid stroma. Which of the following is a characteristic of this lesion?

A. It is also called papillary cystadenoma lymphomatosum.
B. It is most often localized to the submandibular gland.
C. It is the most common malignant salivary gland tumor.
D. Recurrence often takes place after surgical resection. (Correct Answer)

Explanation: **Explanation:** The clinical presentation and histopathology describe a **Pleomorphic Adenoma** (Benign Mixed Tumor), the most common salivary gland tumor. The biopsy findings of epithelial cells (stellate/fusiform) in a myxoid or chondroid stroma are pathognomonic. **Why Option D is Correct:** Pleomorphic adenomas are notorious for **recurrence** if not managed properly. This occurs due to two main reasons: 1. **Pseudopodia:** Microscopic finger-like projections of the tumor extend beyond the main capsule. 2. **Enucleation risks:** Simple enucleation often leaves behind these projections or leads to "seeding" if the capsule ruptures. To prevent recurrence, the standard treatment is **Superficial Parotidectomy** (sparing the facial nerve). **Why Other Options are Incorrect:** * **Option A:** Papillary cystadenoma lymphomatosum is the synonym for **Warthin’s Tumor**, which is characterized by cystic spaces and a dense lymphoid stroma with germinal centers. * **Option B:** Pleomorphic adenoma is most commonly found in the **Parotid gland** (80%), not the submandibular gland. * **Option C:** It is the most common **benign** tumor. The most common malignant salivary gland tumor is **Mucoepidermoid carcinoma**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Superficial lobe of the Parotid gland. * **Risk of Malignancy:** Approximately 3–5% can undergo malignant transformation into **Carcinoma ex pleomorphic adenoma** (suspect if a long-standing mass suddenly grows rapidly or causes facial nerve palsy). * **Hot Spot:** On Tc-99m pertechnetate scan, Warthin’s tumor and Oncocytoma show increased uptake, while Pleomorphic Adenoma appears as a "cold" lesion.

Question 145: A 62-year-old man undergoes excision of a cylindroma of the submandibular gland. He is most likely to have an injury to which of the following nerves?

A. Maxillary branch of the trigeminal nerve
B. Lingual nerve (Correct Answer)
C. Vagus nerve
D. Hypoglossal nerve

Explanation: ### Explanation **Correct Option: B. Lingual nerve** The submandibular gland is located in the submandibular triangle and has a close anatomical relationship with three nerves: the **lingual nerve**, the **hypoglossal nerve**, and the **marginal mandibular branch of the facial nerve**. The **lingual nerve** is the most vulnerable during excision because of its unique "looping" relationship with the submandibular duct (Wharton’s duct). The nerve crosses lateral to the duct, then loops under it to reach the medial side. During surgical mobilization of the gland or ligation of the duct, the lingual nerve is frequently pulled into the surgical field, making it the most commonly injured nerve in this procedure. Injury results in loss of general sensation and taste (via chorda tympani) to the anterior two-thirds of the tongue. **Analysis of Incorrect Options:** * **A. Maxillary branch (V2):** This nerve supplies the mid-face and upper teeth. It is located deep in the pterygopalatine fossa and is not encountered during submandibular surgery. * **C. Vagus nerve:** The vagus nerve lies within the carotid sheath, deep and posterior to the submandibular gland. While it is in the neck, it is not at immediate risk during a standard submandibular gland excision. * **D. Hypoglossal nerve:** While the hypoglossal nerve lies in the floor of the submandibular triangle (deep to the mylohyoid muscle), it is generally better protected and less frequently injured than the lingual nerve during this specific surgery. **NEET-PG High-Yield Pearls:** * **Cylindroma:** This is the historical name for **Adenoid Cystic Carcinoma**, the most common malignant tumor of the submandibular and minor salivary glands. It is notorious for **perineural invasion**. * **Nerve Relationships:** * *Lingual nerve:* Loops under the submandibular duct ("The Water under the Bridge"). * *Marginal Mandibular nerve:* Runs superficial to the submandibular gland; injury causes drooping of the corner of the mouth. * **Surgical Tip:** To protect the marginal mandibular nerve, the incision is made 2 cm below the lower border of the mandible (Hayes Martin maneuver).

Question 146: Carcinoma of the lip is characterized by the following, except:

A. 90% of lip cancers occur on the lower lip.
B. The most common site of origin is the vermillion border.
C. 2 cm x 2 cm cell carcinomas can be treated by V-shaped excision and primary closure.
D. Lymph node metastases are common, making a radical neck dissection mandatory. (Correct Answer)

Explanation: **Explanation:** **1. Why Option D is the correct (False) statement:** Carcinoma of the lip is generally a slow-growing tumor with a **low rate of regional lymph node metastasis** (approximately 5–10% at presentation). Because the risk of occult metastasis is low, prophylactic or radical neck dissection is **not mandatory**. Management of the neck is typically "watchful waiting" or selective neck dissection only if nodes are clinically palpable (N+ neck). **2. Analysis of Incorrect Options (True statements):** * **Option A:** Approximately **90% of lip cancers occur on the lower lip**, primarily due to chronic cumulative solar radiation (UVB exposure). Upper lip cancers are rarer but often more aggressive. * **Option B:** The **vermillion border** (the transition zone between the skin and mucous membrane) is the most common site of origin, particularly for Squamous Cell Carcinoma (SCC). * **Option C:** Small to medium-sized lesions (up to 1/3rd of the lip width, or roughly 2 cm) can be effectively managed with a **V-shaped or W-shaped wedge excision**. The lip has significant laxity, allowing for primary closure with excellent functional and cosmetic results. **Clinical Pearls for NEET-PG:** * **Most common histological type:** Squamous Cell Carcinoma (SCC) is most common on the lower lip; Basal Cell Carcinoma (BCC) is more frequent on the upper lip. * **Risk Factors:** Pipe smoking, tobacco chewing, and chronic sun exposure (Actinic cheilitis). * **Lymphatic Drainage:** The central part of the lower lip drains to **Submental nodes (Level Ia)**, while the lateral parts drain to **Submandibular nodes (Level Ib)**. * **Prognosis:** Lip cancer has the best prognosis among all oral cavity cancers due to early detection and slow spread.

Question 147: In Submandibular gland surgery, which nerve is least likely to be injured?

A. Inferior alveolar nerve (Correct Answer)
B. Hypoglossal nerve
C. Lingual nerve
D. Mandibular branch of facial nerve

Explanation: **Explanation:** The submandibular gland is located in the submandibular triangle, and its surgical removal (excision) requires careful dissection to avoid damaging several closely related nerves. **Why Inferior Alveolar Nerve is the Correct Answer:** The **Inferior Alveolar Nerve** is a branch of the mandibular nerve (V3) that enters the mandibular foramen to supply the lower teeth and chin. It runs deep within the bony canal of the mandible. Since it is protected by bone and is superior to the surgical field of the submandibular gland, it is **least likely** to be injured during routine gland excision. **Analysis of Incorrect Options:** * **Mandibular branch of facial nerve (Marginal Mandibular Nerve):** This is the nerve **most commonly injured** during the initial skin incision. It runs superficial to the submandibular gland fascia. To protect it, the incision is made 2 cm below the lower border of the mandible (Hayes Martin maneuver). * **Lingual Nerve:** This nerve lies deep to the gland and is connected to the submandibular ganglion. It is at risk during the ligation of the submandibular duct (Wharton’s duct), as the nerve "loops" under the duct. * **Hypoglossal Nerve:** This nerve forms the floor of the submandibular triangle (within the Lesser’s triangle). It lies deep to the tendon of the digastric muscle and the submandibular gland; it can be injured during deep dissection. **NEET-PG High-Yield Pearls:** 1. **Most common nerve injured:** Marginal Mandibular Nerve (leads to drooping of the corner of the mouth). 2. **Nerve related to the duct:** The Lingual nerve "double crosses" the submandibular duct. 3. **Incision safety:** Always make the incision 2 cm below the mandible to avoid the marginal mandibular nerve. 4. **Secretomotor pathway:** Parasympathetic fibers to the gland travel via the Chorda Tympani (branch of Facial nerve) and the Lingual nerve.

Question 148: Carcinoma of the tongue most commonly occurs at which location?

A. Dorsum
B. Lateral border of the anterior two-thirds (Correct Answer)
C. Lateral border of the posterior one-third
D. Tip

Explanation: **Explanation:** **Carcinoma of the tongue** is the most common intraoral cancer. The **lateral border of the anterior two-thirds** (oral tongue) is the most frequent site, accounting for approximately 75% of cases. This area is highly susceptible because it is a "dependent" area where carcinogens in saliva (from tobacco and alcohol) pool and remain in prolonged contact with the mucosa. Additionally, chronic mechanical irritation from jagged teeth or ill-fitting dentures often occurs along the lateral margins. **Analysis of Options:** * **Dorsum (Option A):** This is the least common site for malignancy. The thick keratinized epithelium and dense filiform papillae provide a protective barrier against chemical and mechanical trauma. * **Lateral border of the posterior one-third (Option C):** This refers to the base of the tongue (oropharynx). While tumors here are often more aggressive and diagnosed at a later stage due to rich lymphatic drainage, they are statistically less common than those on the anterior lateral borders. * **Tip (Option D):** While possible, the tip is a rare primary site compared to the lateral edges. **Clinical Pearls for NEET-PG:** * **Histology:** Squamous Cell Carcinoma (SCC) is the most common histological type (>90%). * **Lymphatic Spread:** Tongue cancer has a high propensity for early nodal metastasis. The tip drains to **Submental nodes (Level I)**, the lateral borders to **Submandibular nodes (Level I/II)**, and the posterior third directly to **Deep Cervical nodes (Level II/III)**. * **Premalignant Lesions:** Erythroplakia has a much higher transformation rate to malignancy than Leukoplakia. * **Prognosis:** The most important prognostic factor is the presence of cervical lymph node metastasis.

Question 149: Which muscle is resected in a classical neck dissection?

A. Sternohyoid
B. Sternothyroid
C. Sternocleidomastoid (Correct Answer)
D. Sternocricoid

Explanation: In Radical Neck Dissection (RND), also known as **Classical Neck Dissection**, the goal is to remove all lymphatic tissue from Levels I to V on one side of the neck. To ensure complete oncological clearance, three specific non-lymphatic structures are routinely sacrificed. ### 1. Why Sternocleidomastoid (SCM) is Correct The **Sternocleidomastoid muscle** is the primary muscle resected in a classical neck dissection. It is removed to provide adequate exposure and access to the deep cervical lymph nodes (Levels II, III, and IV) that lie beneath and adjacent to it. Along with the SCM, the other two "classical" structures resected are: * **Internal Jugular Vein (IJV)** * **Spinal Accessory Nerve (SAN)** ### 2. Why Other Options are Incorrect * **A & B (Sternohyoid & Sternothyroid):** These are "strap muscles" of the neck. While they may be retracted or occasionally divided in thyroid surgeries or laryngectomies, they are not standard components of a classical neck dissection. * **D (Sternocricoid):** This is not a standard anatomical muscle of the neck; it is likely a distractor. ### 3. NEET-PG High-Yield Pearls * **Modified Radical Neck Dissection (MRND):** This is the most common variant today. It involves the same lymph node clearance as RND but **preserves** one or more of the three non-lymphatic structures (SCM, IJV, or SAN). * *Type I:* Preserves SAN. * *Type II:* Preserves SAN and IJV. * *Type III (Functional Neck Dissection):* Preserves all three (SAN, IJV, and SCM). * **Boundary:** The posterior limit of a classical neck dissection is the anterior border of the **Trapezius muscle**. * **Complication:** Resection of the Spinal Accessory Nerve leads to "Shoulder Syndrome" (shoulder pain and inability to abduct the arm above 90 degrees).

Question 150: Which of the following statements regarding symptomatic thyroglossal duct cysts is true?

A. Over 90% manifest themselves before age 12
B. Treatment includes resection of the hyoid bone (Correct Answer)
C. They usually present as a painful swelling in the lateral neck
D. Approximately 10-15% contain malignant elements

Explanation: ### Explanation **Correct Option: B. Treatment includes resection of the hyoid bone** The definitive surgical management for a thyroglossal duct cyst (TGDC) is the **Sistrunk Procedure**. This is based on the embryological descent of the thyroid gland from the foramen cecum; the duct often passes through or is intimately associated with the body of the hyoid bone. To minimize the high risk of recurrence (which drops from ~50% to <5%), the procedure must include: 1. Excision of the cyst. 2. Removal of the **central portion of the hyoid bone**. 3. Excision of the tract up to the foramen cecum at the base of the tongue. **Analysis of Incorrect Options:** * **A: Over 90% manifest before age 12:** While TGDCs are the most common congenital neck midline mass, they follow a "rule of halves." Approximately 50% present before age 20, but the remaining 50% can manifest in older children and adults. * **C: Painful swelling in the lateral neck:** TGDCs typically present as **painless**, mobile, **midline** swellings (usually infrahyoid). A classic clinical sign is that the mass **moves upward with protrusion of the tongue** and deglutition. Lateral neck swellings are more characteristic of Branchial Cleft Cysts. * **D: 10-15% contain malignant elements:** Malignancy in a TGDC is rare, occurring in **less than 1%** of cases. The most common histological type found is **Papillary Thyroid Carcinoma**. **High-Yield Clinical Pearls for NEET-PG:** * **Embryology:** Derived from the persistent tract of the descending thyroid primordium. * **Location:** Most common site is **infrahyoid** (65%), followed by suprahyoid and at the level of the hyoid. * **Diagnosis:** Ultrasound is the initial investigation of choice to confirm the cyst and ensure a normal thyroid gland is present in the neck (to avoid removing ectopic thyroid tissue). * **Complication:** Infection is common, often following an Upper Respiratory Tract Infection (URTI).

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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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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