Head and Neck Surgery Practice Questions

Q: Which nerve is affected in Shoulder dysfunction Syndrome, a complication of radical node dissection?

Accessory nerve. **Explanation:** **Shoulder Dysfunction Syndrome** is a classic complication following Radical Neck Dissection (RND) caused by injury or sacrifice of the **Spinal Accessory Nerve (CN XI)**. 1. **Why the Accessory Nerve is correct:** The Spinal Accessory Nerve provides motor innervation to the **Sternocleidomastoid** and **Trapezius** muscles. In a classical RND, this nerve is intentionally sacrificed to ensure oncological clearance of Level II-V lymph nodes. Its loss leads to denervation and atrophy of the trapezius, resulting in the clinical triad of Shoulder Dysfunction Syndrome: **shoulder pain, drooping of the shoulder (scapular winging), and inability to abduct the arm above 90 degrees.** 2. **Why other options are incorrect:** * **Vagus Nerve (CN X):** Injury leads to vocal cord paralysis (hoarseness) and loss of gag reflex, but does not affect shoulder mobility. * **Hypoglossal Nerve (CN XII):** Injury results in ipsilateral tongue deviation and atrophy. * **Phrenic Nerve:** Injury leads to ipsilateral diaphragmatic paralysis (seen as an elevated hemidiaphragm on X-ray), affecting respiration rather than shoulder function. **Clinical Pearls for NEET-PG:** * **Modified Radical Neck Dissection (MRND):** Type I MRND specifically aims to **preserve the Spinal Accessory Nerve** to prevent this syndrome. * **Nerve Identification:** The nerve is found at **Erb’s point** (posterior border of SCM) and enters the trapezius approximately 2-3 cm above the clavicle. * **Rehabilitation:** If the nerve is sacrificed, patients require aggressive physical therapy to strengthen the levator scapulae and rhomboid muscles to compensate for the lost trapezius function.

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

None of the above. ### 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).

Q: Extraction of which isolated residual maxillary tooth offers the hazard of fracture of tuberosity?

All of the above. The **maxillary tuberosity** is the rounded eminence found on the posterior surface of the body of the maxilla. It is composed of relatively thin cortical bone and cancellous bone, making it structurally vulnerable during dental extractions. **Why "All of the above" is correct:** The risk of tuberosity fracture is highest when extracting **isolated** maxillary molars (1st, 2nd, or 3rd). When a tooth stands alone (isolated) for a long period, the surrounding alveolar bone often undergoes remodeling. Specifically, the **maxillary sinus** may undergo **pneumatization** (expansion), extending into the tuberosity area. This thins the supporting bone significantly. During extraction, the application of force (especially with forceps or elevators) can cause the weakened bone to "bridge" between the tooth and the tuberosity, leading to a fracture of the entire bony segment rather than a simple tooth delivery. * **3rd Molar:** This is the most common site for fracture due to its proximity to the posterior border of the tuberosity and the presence of divergent roots. * **1st and 2nd Molars:** While slightly less common than the 3rd molar, if these teeth are isolated and the maxillary sinus is low-lying (pneumatized), the risk of fracturing the tuberosity remains high. **High-Yield Clinical Pearls for NEET-PG:** * **Management:** If a tuberosity fracture occurs and the bone is still attached to the periosteum, it should be stabilized and the surgical site closed. If it is completely detached, it is removed, and the clinician must check for an **Oro-antral communication (OAC)**. * **Radiographic Sign:** A large, pneumatized maxillary sinus on a periapical radiograph is a warning sign for potential tuberosity fracture. * **Prevention:** Surgical extraction (sectioning the tooth) is preferred over forceful forceps extraction for isolated maxillary molars to preserve the integrity of the tuberosity.

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

Inferior alveolar nerve. **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.

Q: Which muscle is resected in a classical neck dissection?

Sternocleidomastoid. 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 1

Which nerve is affected in Shoulder dysfunction Syndrome, a complication of radical node dissection?

Accepted Answer

Accessory nerve

Answer

Vagus nerve

Answer

Hypoglossal Nerve

Answer

Phrenic Nerve

Question 2

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

Accepted Answer

None of the above

Answer

Cervical group of lymph nodes

Answer

Sternocleidomastoid muscle

Answer

Internal jugular vein

Question 3

In a Guardsman fracture, what type of fractures are present?

Accepted Answer

Direct fracture of the symphysis with an indirect fracture of the bilateral subcondyle.

Answer

Indirect fracture of the symphysis with a direct fracture of the bilateral subcondyle.

Answer

Direct fracture at both the symphysis and the bilateral subcondyle.

Answer

Any of the above combinations.

Question 4

Extraction of which isolated residual maxillary tooth offers the hazard of fracture of tuberosity?

Accepted Answer

All of the above

Answer

3rd molar

Answer

1st molar

Answer

2nd molar

Question 5

Which of the following statements is true regarding salivary glands?

Accepted Answer

90% of all parotid tumors are malignant.

Answer

There are more than 400 minor salivary glands.

Answer

90% of minor salivary tumors are malignant.

Answer

Superficial parotidectomy is performed for parotid tumors.

Question 6

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?

Accepted Answer

Lingual nerve

Answer

Maxillary branch of the trigeminal nerve

Answer

Vagus nerve

Answer

Hypoglossal nerve

Question 7

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

Accepted Answer

Lymph node metastases are common, making a radical neck dissection mandatory.

Answer

90% of lip cancers occur on the lower lip.

Answer

The most common site of origin is the vermillion border.

Answer

2 cm x 2 cm cell carcinomas can be treated by V-shaped excision and primary closure.

Question 8

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

Accepted Answer

Inferior alveolar nerve

Answer

Hypoglossal nerve

Answer

Lingual nerve

Answer

Mandibular branch of facial nerve

Question 9

Which muscle is resected in a classical neck dissection?

Accepted Answer

Sternocleidomastoid

Answer

Sternohyoid

Answer

Sternothyroid

Answer

Sternocricoid

Question 10

Incision for drainage of parotid abscess is fashioned to avoid damage to which of the following structures?

Accepted Answer

Facial nerve

Answer

Parotid duct

Answer

Retromandibular vein

Answer

Carotid artery

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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