Head and Neck Surgery Practice Questions

Q: Mixed tumors of the salivary glands are:

Most common in the parotid gland.. **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.

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

Hematogenous route. **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*.

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

Osteoradionecrosis of the mandible. **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).

Q: Multiple pencil ulcers are seen in all except?

Carcinomatous ulcers. **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).

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

Nasopharyngeal carcinoma. **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).

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

Infra-hyoid. **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).

Question 1

What is the management of a thyroglossal cyst?

Accepted Answer

The central portion of the thyroid is excised.

Answer

Nodes of the neck are removed.

Answer

Sternocleidomastoid muscle is dissected.

Answer

Subtotal thyroidectomy is performed.

Question 2

Mixed tumors of the salivary glands are:

Accepted Answer

Most common in the parotid gland.

Answer

Most common in the submandibular gland.

Answer

Usually malignant.

Answer

Associated with calculi.

Question 3

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

Accepted Answer

Hematogenous route

Answer

Tissue spaces

Answer

Lymphatic route

Answer

All of the above

Question 4

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

Accepted Answer

Osteoradionecrosis of the mandible

Answer

Sialocele

Answer

Flap necrosis

Answer

Frey's syndrome

Question 5

Multiple pencil ulcers are seen in all except?

Accepted Answer

Carcinomatous ulcers

Answer

Aphthous ulcers

Answer

Herpes ulcers

Answer

Tuberculous ulcers

Question 6

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

Accepted Answer

Nasopharyngeal carcinoma

Answer

Angiofibroma

Answer

Laryngeal carcinoma

Answer

Growth in fossa of Rosenmuller

Question 7

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?

Accepted Answer

Radical neck dissection

Answer

Lower cervical neck dissection

Answer

Suprahyoid neck dissection

Answer

Tele-radiotherapy

Question 8

True about Branchial cyst?

Accepted Answer

Mostly arises from the 2nd branchial system

Answer

Cysts are more common than sinuses

Answer

Causes dysphagia and hoarseness

Answer

Sinus should always be operated

Question 9

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?

Accepted Answer

Segmental mandibulectomy

Answer

Hemi-mandibulectomy

Answer

Commando operation

Answer

Marginal mandibulectomy

Question 10

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

Accepted Answer

Infra-hyoid

Answer

Lingual

Answer

Infra-lingual (caecum)

Answer

Supra-hyoid

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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