Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 151: Incision for drainage of parotid abscess is fashioned to avoid damage to which of the following structures?

A. Facial nerve (Correct Answer)
B. Parotid duct
C. Retromandibular vein
D. Carotid artery

Explanation: **Explanation:** The parotid gland is a wedge-shaped organ divided into superficial and deep lobes by the **facial nerve (CN VII)**, which traverses the gland. When a parotid abscess occurs, it is contained within the dense, unyielding parotid fascia, causing severe pain and requiring surgical drainage. The standard procedure for drainage is the **Hilton’s method** or a modified **Blair’s incision**. The incision is made horizontally (parallel to the branches of the facial nerve) or vertically (pre-auricular). The primary surgical objective is to avoid damaging the facial nerve, as injury leads to permanent facial muscle paralysis. To ensure safety, the skin is incised, and a hemostat is used to bluntly dissect the parotid parenchyma in a direction parallel to the nerve branches. **Analysis of Incorrect Options:** * **B. Parotid duct (Stensen’s duct):** While important, the duct runs horizontally across the masseter muscle and is easily avoided by placing incisions posterior to the anterior border of the gland. * **C. Retromandibular vein:** This vein lies deep to the facial nerve within the gland. While it may be encountered during deep dissection, its injury is less clinically catastrophic than a facial nerve palsy. * **D. Carotid artery:** The external carotid artery lies in the deepest part of the gland. It is rarely at risk during the drainage of a superficial abscess. **Clinical Pearls for NEET-PG:** * **Hilton’s Method:** Used for abscesses near vital structures; involves blunt dissection with a sinus forceps to avoid neurovascular injury. * **Frey’s Syndrome:** A common complication after parotid surgery where gustatory sweating occurs due to cross-innervation between auriculotemporal (parasympathetic) and sympathetic nerves. * **Pus Pointing:** Parotid abscesses rarely "point" to the skin because of the thick parotid fascia; hence, clinical judgment (pitting edema) is used for diagnosis rather than waiting for fluctuation.

Question 152: What is a Warthin's tumor?

A. A benign cystic tumor of the salivary glands
B. A malignant salivary gland tumor
C. A benign salivary gland tumor that shows uptake on a Technetium-99m pertechnetate scan (Correct Answer)
D. A benign salivary gland tumor that does not show uptake on a Technetium-99m pertechnetate scan

Explanation: **Warthin’s Tumor (Papillary Cystadenoma Lymphomatosum)** is the second most common benign salivary gland tumor, typically occurring in the parotid gland. ### **Explanation of the Correct Answer** The correct answer is **Option C**. Warthin’s tumor is unique because it is composed of oncocytes (mitochondria-rich epithelial cells) and a dense lymphoid stroma. These oncocytes have a high metabolic affinity for **Technetium-99m pertechnetate**. On a nuclear medicine scan, Warthin’s tumor appears as a **"Hot Nodule"** because it concentrates the isotope more than the surrounding normal salivary tissue. This is a classic diagnostic feature used to differentiate it from other salivary tumors like Pleomorphic Adenoma, which typically appears "cold." ### **Analysis of Incorrect Options** * **Option A:** While it is a benign cystic tumor, this description is too generic. In the context of NEET-PG, the specific association with the **Tc-99m scan** is the defining characteristic tested. * **Option B:** Warthin’s tumor is strictly **benign**. Malignant transformation is extremely rare (<1%). * **Option D:** This is factually incorrect. Most salivary tumors (like Pleomorphic Adenoma) do not show uptake, but Warthin’s tumor and Oncocytoma are the notable exceptions that **do** show uptake. ### **High-Yield Clinical Pearls for NEET-PG** * **Demographics:** Strongly associated with **smoking** and more common in **males** (though the gender gap is narrowing). * **Location:** Almost exclusively found in the **Parotid gland** (especially the lower pole/tail). * **Multiplicity:** It is the most common salivary tumor to be **bilateral** (10%) or multicentric. * **Pathology:** Characterized by a double layer of eosinophilic epithelium (oncocytes) forming cystic spaces with a lymphoid background (germinal centers). * **Treatment:** Surgical excision (Superficial parotidectomy or Enucleation).

Question 153: What is the most common cyst of ectopic salivary gland?

A. Wharton's cyst
B. Stafne bone cyst
C. Ranula (Correct Answer)
D. Dermoid cyst

Explanation: **Explanation:** A **Ranula** is a clinical term for a mucocele (mucus extravasation cyst) that occurs specifically in the floor of the mouth. It most commonly arises from the **sublingual gland**, which is technically considered an "ectopic" or minor salivary tissue source in the context of these cystic formations when compared to the major parotid or submandibular ducts. The "Plunging Ranula" variant is particularly high-yield, as it herniates through the mylohyoid muscle into the neck. **Analysis of Options:** * **Ranula (Correct):** It is the most frequent cystic lesion associated with salivary tissue dysfunction in the floor of the mouth. While usually arising from the sublingual gland, it is the classic representation of a salivary extravasation cyst. * **Wharton’s Cyst (Incorrect):** This is a distension of Wharton’s duct (submandibular duct), usually due to a sialolith (stone). It is a retention cyst of a major duct, not an ectopic gland cyst. * **Stafne Bone Cyst (Incorrect):** This is not a true cyst but a developmental depression in the mandible containing ectopic submandibular gland tissue. It is asymptomatic and radiolucent on X-ray. * **Dermoid Cyst (Incorrect):** These are developmental cysts containing adnexal structures (hair, sebum). While they appear in the midline of the floor of the mouth, they are not of salivary origin. **Clinical Pearls for NEET-PG:** * **Most common site for Ranula:** Floor of the mouth (sublingual gland). * **Plunging Ranula:** Extends below the **mylohyoid muscle**; presents as a soft, painless neck swelling. * **Treatment of choice:** Surgical excision of the cyst along with the **sublingual gland** to prevent recurrence. * **Appearance:** Often described as having a "blue, translucent, frog-belly" appearance.

Question 154: Which of the following structures is preserved in a Type I modified radical neck dissection?

A. Sternocleidomastoid muscle
B. Spinal accessory nerve (Correct Answer)
C. Level I lymph nodes
D. Internal jugular vein

Explanation: ### Explanation The classification of neck dissections is a high-yield topic for NEET-PG. To understand the **Modified Radical Neck Dissection (MRND)**, one must first understand the **Radical Neck Dissection (RND)**, which involves the removal of lymph node levels I–V along with three non-lymphatic structures: the **Spinal Accessory Nerve (SAN)**, the **Internal Jugular Vein (IJV)**, and the **Sternocleidomastoid (SCM) muscle**. In an MRND, the same lymph node levels (I–V) are removed, but one or more of the non-lymphatic structures are preserved. The types are defined by what is **preserved**: * **Type I:** Preservation of the **Spinal Accessory Nerve** (SAN). * **Type II:** Preservation of the **SAN** and the **Internal Jugular Vein** (IJV). * **Type III:** Preservation of all three: **SAN, IJV, and SCM muscle** (also known as Functional Neck Dissection). #### Analysis of Options: * **B (Correct):** In Type I MRND, only the SAN is spared to prevent "shoulder syndrome" (shoulder drop and pain due to trapezius paralysis). * **A & D (Incorrect):** The SCM and IJV are sacrificed in Type I MRND. They are only preserved in Type III (both) or Type II (IJV). * **C (Incorrect):** Level I lymph nodes are part of the standard nodal clearance (Levels I–V) for both RND and MRND. If specific levels are spared, it is termed a "Selective Neck Dissection." ### High-Yield Clinical Pearls: * **Most common structure preserved:** The SAN is prioritized to maintain shoulder function. * **Bilateral Neck Dissection:** If both sides require surgery, at least one IJV should be preserved (Type II or III) to prevent intracranial hypertension and facial edema. * **Boundary of Level II and III:** The hyoid bone (or the bifurcation of the carotid artery) serves as the landmark. * **Erb’s Point:** The location where the SAN emerges behind the SCM, a critical landmark during surgery.

Question 155: Which of the following statements about hygromas is false?

A. Most common location is the posterior fossa.
B. Filled with blood. (Correct Answer)
C. Filled with lymph.
D. Associated with Turner's syndrome.

Explanation: **Cystic Hygromas** (also known as macrocystic lymphatic malformations) are congenital malformations of the lymphatic system. ### **Explanation of the Correct Answer** **Option B is False (Correct Answer):** Cystic hygromas are **not filled with blood**. They are benign malformations of the lymphatic vessels that fail to communicate with the venous system. Consequently, they are filled with **clear, straw-colored lymph**. If a similar lesion were filled with blood, it would be classified as a hemangioma or a venous malformation. ### **Analysis of Other Options** * **Option A (True):** The most common location is the **posterior triangle of the neck** (approximately 75-80% of cases). Other sites include the axilla, mediastinum, and groin. * **Option C (True):** As lymphatic malformations, they are characteristically filled with protein-rich lymphatic fluid. * **Option D (True):** There is a strong clinical association between cystic hygromas and chromosomal abnormalities, most notably **Turner’s syndrome (45, XO)**, as well as Down syndrome (Trisomy 21) and Noonan syndrome. ### **NEET-PG High-Yield Pearls** * **Clinical Presentation:** Presents as a soft, painless, compressible, and **brilliantly transilluminant** mass. * **Pathology:** Characterized by large, dilated lymphatic spaces lined by a single layer of flattened endothelial cells. * **Complications:** Sudden increase in size usually indicates secondary infection or intralesional hemorrhage. * **Management:** Surgical excision is the traditional gold standard. However, **Sclerotherapy** (using agents like OK-432, Bleomycin, or Doxycycline) is now frequently used, especially for macrocystic lesions, to avoid injury to vital neck structures.

Question 156: Surgery of choice for pleomorphic adenoma is:

A. Total parotidectomy
B. Superficial parotidectomy (Correct Answer)
C. Total parotidectomy with lymph node dissection
D. Radical parotidectomy

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 correct:** The standard surgical management for a pleomorphic adenoma located in the superficial lobe is **superficial parotidectomy** (removal of the gland superficial to the facial nerve). This procedure ensures adequate margins while identifying and preserving the facial nerve. Simple enucleation is strictly contraindicated because the tumor often possesses "pseudopods" (microscopic finger-like projections) that penetrate the capsule; enucleation leaves these behind, leading to high recurrence rates. 2. **Why other options are incorrect:** * **Total Parotidectomy:** This involves removing both the superficial and deep lobes. It is reserved for tumors involving the deep lobe or recurrent cases. It is not the primary choice for standard superficial tumors. * **Total Parotidectomy with Lymph Node Dissection:** This is indicated for high-grade malignancies with suspected nodal metastasis. Pleomorphic adenoma is benign and does not require neck dissection. * **Radical Parotidectomy:** This involves the sacrifice of the facial nerve. It is only indicated for invasive malignancies where the nerve cannot be separated from the tumor. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Tail of the parotid gland. * **Facial Nerve:** The facial nerve divides the parotid into superficial and deep lobes (Patey’s maneuver). * **Frey’s Syndrome:** The most common late complication of parotidectomy, diagnosed by the **Minor’s Starch-Iodine test**. * **Malignant Transformation:** Long-standing pleomorphic adenomas can transform into **Carcinoma ex-pleomorphic adenoma** (sudden rapid growth).

Question 157: Which of the following is the most common cause of late neurological deterioration following a cerebrovascular accident?

A. Rebleeding
B. Vasospasm (Correct Answer)
C. Embolism
D. Hydrocephalus

Explanation: **Explanation:** The correct answer is **Vasospasm**. In the context of a cerebrovascular accident (specifically Subarachnoid Hemorrhage - SAH), neurological deterioration follows a predictable timeline. While the initial ictus causes immediate damage, **delayed cerebral ischemia (DCI)** due to vasospasm is the most common cause of secondary or "late" neurological decline. * **Why Vasospasm is correct:** Cerebral vasospasm typically occurs **3 to 14 days** after the initial bleed (peaking at 7–10 days). It is caused by the breakdown of red blood cells in the subarachnoid space, releasing oxyhemoglobin and other spasmogenic substances that lead to prolonged arterial constriction, resulting in secondary ischemic stroke. **Analysis of Incorrect Options:** * **Rebleeding:** This is the most common cause of death in the **first 24 hours** post-SAH. While it causes deterioration, it is considered an early complication rather than the classic "late" deterioration associated with vasospasm. * **Embolism:** While a cause of primary ischemic stroke, it is not the standard mechanism for delayed deterioration following a hemorrhagic CVA. * **Hydrocephalus:** This can occur early (acute) or late (chronic). While it causes neurological symptoms (e.g., altered sensorium), it is less frequent as a cause of focal neurological deficits compared to vasospasm. **Clinical Pearls for NEET-PG:** * **Prophylaxis:** **Nimodipine** (a calcium channel blocker) is the gold standard drug used to improve outcomes in SAH patients by reducing the incidence of ischemic deficits. * **Management:** The traditional "Triple-H" therapy (Hypervolemia, Hypertension, Hemodilution) has largely shifted toward maintaining **induced hypertension** to ensure cerebral perfusion. * **Diagnosis:** Digital Subtraction Angiography (DSA) is the gold standard, but Transcranial Doppler (TCD) is used for daily bedside monitoring of flow velocities.

Question 158: What is the term for the removal of level I to V lymph nodes along with the sternocleidomastoid muscle?

A. Selective neck dissection
B. Modified radical neck dissection (Correct Answer)
C. Radical neck dissection
D. Functional neck dissection

Explanation: ### Explanation The classification of neck dissections is a high-yield topic in surgical oncology, primarily based on which lymph node levels (I-V) and non-lymphatic structures are removed. **1. Why "Modified Radical Neck Dissection" (MRND) is correct:** A **Radical Neck Dissection (RND)** involves the removal of lymph node levels I through V plus three non-lymphatic structures: the Sternocleidomastoid muscle (SCM), the Internal Jugular Vein (IJV), and the Spinal Accessory Nerve (SAN). **Modified Radical Neck Dissection (MRND)** involves the same lymph node levels (I-V) but **preserves one or more** of these non-lymphatic structures. In this specific question, the SCM is removed, implying that the IJV and/or SAN are preserved, thus categorizing it as MRND. **2. Analysis of Incorrect Options:** * **Selective Neck Dissection (SND):** Only specific lymph node levels are removed (e.g., Levels I-III in supraomohyoid dissection) based on the primary tumor site. It does not involve all levels I-V. * **Radical Neck Dissection (RND):** This requires the removal of **all three** non-lymphatic structures (SCM, IJV, and SAN) along with levels I-V. If any one of these is preserved, it is no longer an RND. * **Functional Neck Dissection:** This is an older term often used synonymously with MRND Type III, where levels I-V are removed but **all three** non-lymphatic structures (SCM, IJV, SAN) are preserved. **3. NEET-PG Clinical Pearls:** * **MRND Type I:** SAN is preserved. * **MRND Type II:** SAN and IJV are preserved. * **MRND Type III:** SAN, IJV, and SCM are preserved (most common for N0 necks). * The **Spinal Accessory Nerve** is the most important structure to preserve to prevent "Shoulder Syndrome" (pain and limited abduction). * **Level VI** nodes (pre-tracheal/para-tracheal) are typically addressed in thyroid and laryngeal cancers, not in standard RND/MRND.

Question 159: Which of the following is NOT a typical feature of extradural hemorrhage?

A. Severe hypotension (Correct Answer)
B. Deteriorating consciousness
C. Fixed dilated pupil on the same side
D. Fracture line crossing the temporal bone

Explanation: **Explanation:** **1. Why Severe Hypotension is the Correct Answer:** In neurosurgery, the "Monro-Kellie doctrine" explains that the cranial vault is a rigid box. An extradural hemorrhage (EDH) increases intracranial pressure (ICP), which triggers the **Cushing Reflex** (hypertension, bradycardia, and irregular respiration). Therefore, patients with isolated head injuries typically present with **hypertension**, not hypotension. If a patient with EDH is hypotensive, the clinician must look for extracranial causes of bleeding (e.g., intra-abdominal or thoracic hemorrhage), as the adult skull cannot lose enough blood into the epidural space to cause systemic shock. **2. Analysis of Incorrect Options:** * **Deteriorating consciousness:** This is a hallmark of EDH. While some patients experience a "Lucid Interval," the subsequent hematoma expansion leads to rapid neurological decline due to brain compression. * **Fixed dilated pupil on the same side:** This occurs due to **uncal herniation**. The expanding hematoma pushes the temporal lobe (uncus) medially, compressing the ipsilateral 3rd cranial nerve (Oculomotor), leading to a dilated, non-reactive pupil. * **Fracture line crossing the temporal bone:** EDH is most commonly caused by a tear in the **middle meningeal artery** (85% of cases), which lies beneath the pterion. A temporal bone fracture is the classic inciting event. **Clinical Pearls for NEET-PG:** * **Classic Imaging:** CT scan shows a **Biconvex/Lenticular** hyperdense shape (does not cross suture lines). * **Source of Bleed:** Middle Meningeal Artery (most common) or Dural Venous Sinuses. * **Lucid Interval:** A period of temporary improvement followed by rapid deterioration; highly characteristic of EDH. * **Management:** Immediate surgical evacuation via burr hole or craniotomy if the hematoma is significant.

Question 160: Which is the most common childhood central nervous system (CNS) tumor to metastasize outside the brain?

A. Ependymoma
B. Glioblastoma multiforme
C. Choroid plexus tumor
D. Medulloblastoma (Correct Answer)

Explanation: **Explanation:** **Medulloblastoma** is the most common malignant brain tumor in children, typically arising from the cerebellum (roof of the 4th ventricle). It is highly invasive and has a unique propensity for dissemination via the cerebrospinal fluid (CSF), known as "drop metastasis" to the spinal cord. Importantly, it is the **most common CNS tumor in children to metastasize outside the neuraxis** (extracranial metastasis). The most frequent sites for systemic spread are the **bone (most common)** and bone marrow, followed by the lymph nodes and liver. This spread often occurs after surgical intervention or via ventriculoperitoneal (VP) shunts. **Analysis of Incorrect Options:** * **Ependymoma:** While these can show CSF dissemination (especially the anaplastic subtype), systemic extracranial metastasis is extremely rare compared to medulloblastoma. * **Glioblastoma Multiforme (GBM):** This is the most common primary malignant brain tumor in *adults*. While it is highly aggressive locally, it rarely metastasizes outside the CNS in the pediatric population. * **Choroid Plexus Tumor:** These are rare intraventricular tumors. While Choroid Plexus Carcinomas can spread via CSF, they do not have the same high incidence of systemic metastasis as medulloblastoma. **High-Yield Clinical Pearls for NEET-PG:** * **Homer-Wright Rosettes:** A classic histopathological finding in medulloblastoma (also seen in Neuroblastoma). * **Location:** Arises from the **vermis** in children (midline) and cerebellar hemispheres in adults. * **Genetic Association:** Often associated with **Turcot Syndrome** (Type 1) and **Gorlin Syndrome**. * **Management:** Requires a multidisciplinary approach including maximal safe resection, craniospinal irradiation (in children >3 years), and chemotherapy.

Practice by Chapter

Salivary Gland Diseases

Practice Questions

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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