Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 171: What is the management of a thyroglossal cyst?

A. Nodes of the neck are removed.
B. Sternocleidomastoid muscle is dissected.
C. The central portion of the thyroid is excised. (Correct Answer)
D. Subtotal thyroidectomy is performed.

Explanation: ### Explanation **Correct Answer: C. The central portion of the hyoid bone is excised.** *(Note: While the option text says "central portion of the thyroid," in the context of standard surgical literature and NEET-PG patterns, this refers to the **Sistrunk Procedure**, where the central part of the **hyoid bone** is excised. If the option explicitly says "thyroid," it is likely a typographical error in the question source for "hyoid," as this is the definitive management step.)* The **Sistrunk Procedure** is the gold standard for treating a thyroglossal cyst. Because the thyroglossal duct embryologically migrates from the foramen caecum to the thyroid's final position, it passes through or is closely related to the hyoid bone. To minimize the high risk of recurrence (which is ~50% with simple excision), the surgeon must remove: 1. The cyst itself. 2. The **central portion of the hyoid bone**. 3. A core of tissue up to the foramen caecum at the base of the tongue. **Why other options are incorrect:** * **Option A & B:** Thyroglossal cysts are benign developmental anomalies. Radical neck dissection (removing nodes) or SCM dissection is reserved for malignancies and is not part of standard management. * **Option D:** Subtotal thyroidectomy is used for multinodular goiter or Graves' disease. It is unnecessary here unless a rare thyroglossal duct carcinoma is present and involves the main thyroid gland. **Clinical Pearls for NEET-PG:** * **Location:** Most common midline neck swelling in children; moves upward on **protrusion of the tongue** (due to attachment to the foramen caecum). * **Ectopic Thyroid:** Always perform an **Ultrasound** or Thyroid Scan before surgery to ensure the cyst isn't the patient's only functioning thyroid tissue. * **Complication:** If infected, it may rupture to form a **thyroglossal fistula** (usually secondary, not congenital). * **Malignancy:** Most common cancer in a thyroglossal cyst is **Papillary Carcinoma of the Thyroid**.

Question 172: Mixed tumors of the salivary glands are:

A. Most common in the submandibular gland.
B. Usually malignant.
C. Most common in the parotid gland. (Correct Answer)
D. Associated with calculi.

Explanation: **Explanation:** **Pleomorphic Adenoma**, commonly known as a **Mixed Tumor**, is the most common benign tumor of the salivary glands. It is termed "mixed" because it contains both epithelial and mesenchymal elements (myxoid, chondroid, or osteoid tissue) derived from a single germ layer (ectoderm). 1. **Why Option C is Correct:** Approximately **80% of all salivary gland tumors** occur in the parotid gland, and about **80% of parotid tumors** are Pleomorphic Adenomas. This makes the parotid gland the most frequent site of occurrence. 2. **Why Option A is Incorrect:** While they can occur in the submandibular gland, they are significantly less common there than in the parotid. 3. **Why Option B is Incorrect:** Pleomorphic adenomas are **benign**. However, if left untreated for a long duration (typically 10–15 years), they can undergo malignant transformation into **Carcinoma ex-pleomorphic adenoma** (risk is ~3–5%). 4. **Why Option D is Incorrect:** Salivary calculi (Sialolithiasis) are most commonly associated with the **submandibular gland** (80%) due to the alkaline, calcium-rich nature of its secretions and the upward course of Wharton’s duct. They are not a feature of mixed tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Presentation:** A painless, slow-growing, mobile, firm swelling at the angle of the jaw. * **Nerve Involvement:** Facial nerve palsy is **rare** in benign pleomorphic adenoma; its presence strongly suggests malignancy. * **Treatment:** Superficial parotidectomy (to avoid the facial nerve). Simple enucleation is contraindicated due to a high recurrence rate caused by pseudopod extensions through the capsule. * **Rule of 80s:** 80% occur in the parotid, 80% are pleomorphic adenomas, and 80% are benign.

Question 173: Cavernous sinus thrombosis can occur due to spread of odontogenic infection via:

A. Tissue spaces
B. Lymphatic route
C. Hematogenous route (Correct Answer)
D. All of the above

Explanation: **Explanation:** **1. Why Hematogenous Route is Correct:** Cavernous Sinus Thrombosis (CST) following an odontogenic infection occurs primarily through **hematogenous spread**. The facial and ophthalmic veins are **valveless**, allowing for retrograde blood flow. Infections from the "danger area of the face" or the maxillary teeth can travel via two main pathways: * **Anterior Route:** From the facial vein to the superior/inferior ophthalmic veins, leading directly into the cavernous sinus. * **Posterior Route:** From the **pterygoid venous plexus** through the emissary veins (passing through the foramen ovale or vesalius) into the cavernous sinus. **2. Why Other Options are Incorrect:** * **Tissue Spaces:** While odontogenic infections frequently spread to fascial spaces (e.g., submandibular or buccal spaces) causing cellulitis or Ludwig’s angina, this is a localized spread. It does not directly cause sinus thrombosis unless the infection subsequently enters the venous system. * **Lymphatic Route:** Lymphatic drainage from the teeth and oral cavity primarily goes to the submental, submandibular, and deep cervical lymph nodes. It does not communicate with the dural venous sinuses. **3. NEET-PG High-Yield Pearls:** * **Danger Area of the Face:** Bound by the bridge of the nose and the corners of the mouth. * **Clinical Presentation:** Look for "Staircase sign" (rapidly progressing edema), proptosis, chemosis, and **Cranial Nerve palsies** (CN III, IV, V1, V2, and VI). * **CN VI (Abducens):** Usually the first nerve affected because it runs centrally through the sinus, whereas others are in the lateral wall. * **Source:** The most common cause of CST is *Staphylococcus aureus*.

Question 174: Which of the following is NOT a complication associated with parotidectomy?

A. Sialocele
B. Flap necrosis
C. Frey's syndrome
D. Osteoradionecrosis of the mandible (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Osteoradionecrosis of the mandible.** **Why it is the correct answer:** Osteoradionecrosis (ORN) is a complication of **high-dose radiotherapy** to the head and neck region, not the surgical procedure of parotidectomy itself. It occurs due to radiation-induced hypocellularity, hypovascularity, and hypoxia of the bone, leading to non-healing bone exposure. While a patient might receive radiotherapy *after* parotidectomy for malignancy, ORN is a side effect of the radiation treatment, not a direct surgical complication of the parotid gland excision. **Why the other options are incorrect:** * **Sialocele (A):** This is a common early complication where saliva collects under the skin flap due to leakage from the residual parotid parenchyma or ductal remnants. * **Flap Necrosis (B):** Like any major surgery involving skin flaps, poor vascularity, excessive tension, or hematoma formation can lead to necrosis of the overlying skin flap. * **Frey’s Syndrome (C):** Also known as auriculotemporal syndrome, this is a classic late complication. It occurs due to aberrant regeneration of parasympathetic secretomotor fibers (from the auriculotemporal nerve) which mistakenly join the sympathetic fibers supplying sweat glands. This results in gustatory sweating (sweating while eating). **NEET-PG High-Yield Pearls:** * **Most common complication overall:** Temporary facial nerve neurapraxia. * **Frey’s Syndrome Diagnosis:** Confirmed by the **Minor’s Starch-Iodine test**. * **Prevention of Frey’s:** Use of interpositional barriers like the SMAS flap or acellular dermal matrix. * **Nerve most commonly sacrificed in radical parotidectomy:** Facial nerve (CN VII). * **Nerve often sacrificed to gain access:** Greater auricular nerve (leads to numbness of the earlobe).

Question 175: Multiple pencil ulcers are seen in all except?

A. Aphthous ulcers
B. Herpes ulcers
C. Tuberculous ulcers
D. Carcinomatous ulcers (Correct Answer)

Explanation: **Explanation:** The term **"Pencil Ulcers"** (also known as "punched-out" or "shallow" ulcers) refers to multiple, small, discrete, and painful ulcerations typically seen in inflammatory or infective conditions of the oral mucosa. **Why Carcinomatous Ulcer is the Correct Answer:** Carcinomatous ulcers (Malignant ulcers) are characterized by an **everted (rolled-out) edge** and a hard, **indurated base**. They are typically **solitary**, progressive, and painless in the early stages. They do not present as multiple small "pencil" ulcers; instead, they represent a single focus of uncontrolled cellular proliferation and tissue destruction. **Analysis of Incorrect Options:** * **Aphthous Ulcers:** These are the most common cause of multiple small, painful, shallow ulcers with a yellowish-grey floor and a surrounding red halo. They fit the "pencil ulcer" description perfectly. * **Herpes Ulcers:** Viral infections like Herpes Simplex (Herpetic Gingivostomatitis) present as clusters of small vesicles that rupture to form multiple, shallow, "punched-out" circular ulcers. * **Tuberculous Ulcers:** While rare, secondary TB of the oral cavity presents as multiple, shallow, extremely painful ulcers with **undermined edges**. In clinical practice, these are often grouped with small, multiple inflammatory ulcers. **NEET-PG High-Yield Pearls:** * **Edge Characteristics:** * *Everted:* Squamous Cell Carcinoma. * *Undermined:* Tuberculosis. * *Punched-out:* Syphilis (Gummatous) or Trophic ulcers. * *Sloping:* Healing ulcer. * *Rolled-in/Beaded:* Basal Cell Carcinoma (Rodent ulcer). * **Induration** is the clinical hallmark of malignancy. * **Aphthous ulcers** are associated with HLA-B51 (Behçet’s disease).

Question 176: Trotter's triad is seen in which of the following conditions?

A. Angiofibroma
B. Nasopharyngeal carcinoma (Correct Answer)
C. Laryngeal carcinoma
D. Growth in fossa of Rosenmuller

Explanation: **Explanation:** **Trotter’s Triad** is a classic clinical diagnostic feature of **Nasopharyngeal Carcinoma (NPC)**, typically occurring when the tumor invades the lateral pharyngeal wall (specifically the sinus of Morgagni). The triad consists of: 1. **Ipsilateral Conductive Hearing Loss:** Caused by Eustachian tube obstruction leading to serous otitis media. 2. **Ipsilateral Temporofacial Neuralgia:** Due to involvement of the Mandibular nerve (V3) as it exits the foramen ovale, causing pain in the jaw and temple. 3. **Ipsilateral Palatal Paralysis:** Caused by infiltration of the Levator veli palatini muscle or the Vagus nerve, leading to immobility of the soft palate. **Analysis of Options:** * **Nasopharyngeal Carcinoma (Correct):** This is the definitive condition associated with the triad. The tumor most commonly originates in the **Fossa of Rosenmuller**. * **Growth in Fossa of Rosenmuller (Incorrect):** While NPC often starts here, "Growth" is a non-specific term. In the context of NEET-PG, the specific pathological diagnosis (NPC) is the preferred answer over the anatomical site. * **Angiofibroma (Incorrect):** Juvenile Nasopharyngeal Angiofibroma (JNA) typically presents with painless, profuse epistaxis and nasal obstruction in adolescent males, not the neurological deficits of Trotter’s triad. * **Laryngeal Carcinoma (Incorrect):** This presents with hoarseness of voice, stridor, or dysphagia, depending on the subsite (glottic vs. supraglottic). **High-Yield Clinical Pearls:** * **EBV Association:** NPC is strongly linked to the Epstein-Barr Virus. * **Most Common Site:** Fossa of Rosenmuller. * **Nodal Spread:** The most common presenting symptom of NPC is actually a painless neck mass (level II/V nodes), often involving the **Node of Rouviere** (lateral retropharyngeal node).

Question 177: A patient with carcinoma of the tongue presents with palpable lymph nodes in the lower neck. What is the treatment of choice for these lymph nodes?

A. Lower cervical neck dissection
B. Suprahyoid neck dissection
C. Tele-radiotherapy
D. Radical neck dissection (Correct Answer)

Explanation: **Explanation:** The management of the neck in oral cavity cancers depends on the clinical stage of the nodal disease. In this case, the presence of **palpable lymph nodes in the lower neck** (Level IV or V) signifies advanced nodal spread (N2 or N3 stage). **1. Why Radical Neck Dissection (RND) is correct:** For clinically positive nodes (N+ neck), especially when lower cervical nodes are involved, a comprehensive clearance is required. **Radical Neck Dissection** (Crile’s operation) is the gold standard for advanced nodal disease. It involves the removal of lymph node levels I-V along with three non-lymphatic structures: the Sternocleidomastoid muscle (SCM), the Internal Jugular Vein (IJV), and the Spinal Accessory Nerve (SAN). This ensures maximum oncological clearance in the presence of gross metastatic disease. **2. Why other options are incorrect:** * **Lower cervical neck dissection:** This is an incomplete procedure. Neck dissection for tongue cancer must always include the upper levels (I, II, III) as they are the primary zones of drainage. * **Suprahyoid neck dissection:** This only removes Level I nodes. It is considered oncologically inadequate for tongue cancer, as the tongue frequently skips to Level II and III (jugulodigastric and jugulo-omohyoid nodes). * **Tele-radiotherapy:** While radiotherapy is used as an adjuvant treatment or for palliative care, the primary "treatment of choice" for resectable palpable nodal disease in head and neck squamous cell carcinoma (HNSCC) remains surgical excision. **Clinical Pearls for NEET-PG:** * **Most common site for tongue cancer:** Lateral border of the tongue. * **Lymphatic drainage:** The tip of the tongue drains to Level I (Submental), while the lateral borders drain to Levels II and III. * **Modified Radical Neck Dissection (MRND):** Preferred over RND if the SAN, IJV, or SCM can be oncologically preserved to reduce morbidity (e.g., shoulder syndrome). * **Sentinel Lymph Node Biopsy:** Emerging as a tool for N0 necks (clinically negative) to avoid unnecessary neck dissections.

Question 178: True about Branchial cyst?

A. Cysts are more common than sinuses
B. Mostly arises from the 2nd branchial system (Correct Answer)
C. Causes dysphagia and hoarseness
D. Sinus should always be operated

Explanation: **Explanation:** **1. Why the correct answer is right:** Branchial cysts are congenital epithelial cysts arising from the failure of the **second branchial cleft** to involute during embryonic development. Specifically, they result from the persistence of the **Cervical Sinus of His**. Statistically, approximately **95%** of all branchial anomalies originate from the second branchial system, making it the most common site. These typically present as a painless, fluctuant swelling at the junction of the upper third and middle third of the sternocleidomastoid muscle. **2. Why the other options are wrong:** * **Option A:** In clinical practice, **fistulae and sinuses** are more common than cysts, especially in children. Cysts often remain asymptomatic until they enlarge or become infected, usually in early adulthood. * **Option C:** Branchial cysts are typically located superficially. While they can become large, they rarely compress the esophagus or recurrent laryngeal nerve; therefore, **dysphagia and hoarseness** are not characteristic symptoms. Such symptoms should raise suspicion of a malignant neck mass. * **Option D:** While surgery is the definitive treatment, the statement "always" is a clinical absolute. Surgery is indicated for symptomatic relief or to prevent recurrent infection, but the primary reason this option is incorrect is that **Option B** is a more fundamental and universally true anatomical fact. **3. Clinical Pearls for NEET-PG:** * **Location:** Second branchial anomalies are found along the **anterior border of the sternocleidomastoid muscle**. * **Internal Opening:** If a second branchial fistula is present, the internal opening is consistently found in the **tonsillar fossa**. * **Path of Fistula:** It passes between the internal and external carotid arteries (bifurcation), staying superficial to the glossopharyngeal and hypoglossal nerves. * **Fluid Analysis:** Aspiration of a branchial cyst typically reveals **straw-colored fluid** containing **cholesterol crystals**.

Question 179: A 80-year-old edentulous male patient presents with a midline tumor of the lower jaw, involving the alveolar margin. What is the treatment of choice?

A. Hemi-mandibulectomy
B. Commando operation
C. Segmental mandibulectomy (Correct Answer)
D. Marginal mandibulectomy

Explanation: ### Explanation The management of mandibular involvement in oral cavity cancers depends on the depth of invasion and the quality of the bone. **Why Segmental Mandibulectomy is Correct:** In an **80-year-old edentulous patient**, the mandible undergoes significant atrophy. The vertical height of the bone is greatly reduced, and the **inferior alveolar artery** (the primary blood supply in younger adults) often becomes obliterated. In such patients, the bone receives its blood supply primarily from the periosteum. * **Marginal mandibulectomy** (removing only the upper rim) is contraindicated here because the remaining bone would be too thin and devascularized, leading to a high risk of **pathological fracture** and poor healing. * Therefore, a **segmental mandibulectomy** (full-thickness resection of a bone segment) is required to ensure oncological clearance and avoid postoperative complications. **Analysis of Incorrect Options:** * **A. Hemi-mandibulectomy:** This involves removing half of the mandible from the midline to the condyle. It is overly aggressive for a midline tumor unless the entire half is involved. * **B. Commando operation:** (Composite Resection) This refers to a glossectomy/buccal mucosa resection + mandibulectomy + neck dissection. While a neck dissection may be needed, the question specifically asks for the treatment of the **jaw tumor** itself. * **D. Marginal mandibulectomy:** This is the treatment of choice for superficial alveolar involvement in **dentate patients** with adequate mandibular height (>1 cm of residual bone). It is avoided in the elderly edentulous for the reasons stated above. **High-Yield Clinical Pearls for NEET-PG:** 1. **Rule of Thumb:** If the distance between the tumor and the lower border of the mandible is <1 cm in an edentulous patient, always perform a segmental resection. 2. **Blood Supply:** In young adults, the mandible is supplied by the **inferior alveolar artery** (centrifugal flow); in the elderly, it is supplied by the **periosteal vessels** (centripetal flow). 3. **Imaging:** A **Panorex (OPG)** is the initial screening tool, but a **CT scan (Dental CT)** is superior for assessing cortical erosion.

Question 180: What is the most common anatomical location of a thyroglossal cyst?

A. Lingual
B. Infra-lingual (caecum)
C. Supra-hyoid
D. Infra-hyoid (Correct Answer)

Explanation: **Explanation:** The **thyroglossal cyst** is the most common congenital neck swelling. It develops from a persistent segment of the thyroglossal duct, which marks the descent of the thyroid gland from the foramen caecum at the base of the tongue to its final pre-tracheal position. **Why Infra-hyoid is correct:** While a thyroglossal cyst can occur anywhere along the migratory path of the duct, the **infra-hyoid** position (specifically just below the hyoid bone) is the most frequent site, accounting for approximately **65% of cases**. The cyst is typically midline and moves upward on protrusion of the tongue due to its attachment to the hyoid bone via the tract. **Analysis of Incorrect Options:** * **A. Lingual:** This is the highest possible location (within the tongue). It is rare, occurring in less than 2% of cases. * **B. Infra-lingual (Sublingual):** Located between the tongue and the hyoid bone. While more common than lingual, it is less frequent than the infra-hyoid variety. * **C. Supra-hyoid:** Located just above the hyoid bone. This accounts for about 20-25% of cases, making it the second most common site, but still less frequent than infra-hyoid. **High-Yield Clinical Pearls for NEET-PG:** * **Sistrunk Operation:** The definitive surgical treatment. It involves excision of the cyst, the entire tract, and the **central body of the hyoid bone** to minimize recurrence. * **Movement:** It moves upward on **deglutition** (swallowing) AND **protrusion of the tongue**. * **Carcinoma:** If a malignancy develops within a thyroglossal cyst (rare, <1%), the most common histological type is **Papillary Carcinoma of the Thyroid**. * **Differential Diagnosis:** Always perform an ultrasound to ensure a normal thyroid gland is present in the neck before excision, as the cyst may contain the patient's only functioning thyroid tissue (Ectopic Thyroid).

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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