Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 181: Sistrunk operation is used for the treatment of:

A. Pharyngeal pouch
B. Cystic hygroma
C. Thyroglossal duct cyst (Correct Answer)
D. Sternocleidomastoid tumor

Explanation: **Explanation:** The **Sistrunk operation** is the gold-standard surgical treatment for a **Thyroglossal Duct Cyst (TGDC)**. Because the thyroglossal duct's embryological descent is intimately associated with the hyoid bone, simple excision of the cyst results in a high recurrence rate (approx. 50%). The Sistrunk procedure reduces recurrence to <5% by performing a radical excision that includes: 1. The cyst itself. 2. The entire thyroglossal tract. 3. The **central portion of the hyoid bone**. 4. A core of tongue base muscle up to the foramen caecum. **Analysis of Incorrect Options:** * **A. Pharyngeal pouch (Zenker’s Diverticulum):** Treated via endoscopic stapling (Dohlman’s procedure) or open diverticulectomy with cricopharyngeal myotomy. * **B. Cystic hygroma:** Primarily managed with sclerotherapy (e.g., OK-432, Bleomycin) or surgical excision if localized; it does not involve the hyoid bone. * **C. Sternocleidomastoid tumor:** Associated with congenital muscular torticollis; managed with physiotherapy or, if refractory, bipolar release of the SCM muscle. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** TGDC is most commonly found in the **subhyoid** position (65%). * **Clinical Sign:** It is a midline neck swelling that **moves upward on protrusion of the tongue** (due to its attachment to the foramen caecum via the hyoid). * **Diagnosis:** Ultrasound is the initial investigation to confirm the cyst and ensure a normal thyroid gland is present in the neck. * **Complication:** The most common malignancy arising in a TGDC is **Papillary Thyroid Carcinoma**.

Question 182: What is true about tumors of the salivary glands?

A. The most common site is the parotid gland. (Correct Answer)
B. Enucleation is the treatment of choice.
C. Fine Needle Aspiration Cytology (FNAC) is mandatory.
D. The most common site of origin is the deep lobe.

Explanation: ### Explanation **1. Why Option A is Correct:** The parotid gland is the most common site for salivary gland tumors, accounting for approximately **80%** of all cases. A useful rule of thumb in salivary gland pathology is the "Rule of 80s": 80% of tumors occur in the parotid, and 80% of parotid tumors are benign (most commonly Pleomorphic Adenoma). **2. Why the Other Options are Incorrect:** * **Option B:** Enucleation (simple shelling out of the tumor) is contraindicated because pleomorphic adenomas often have pseudopods (microscopic extensions) through the capsule. Enucleation leads to high recurrence rates. The standard treatment for a parotid tumor is **Superficial Parotidectomy** (if in the superficial lobe) with preservation of the facial nerve. * **Option C:** While FNAC is a highly useful diagnostic tool with high sensitivity and specificity, it is **not mandatory** if the clinical diagnosis is clear and surgery is already indicated. Imaging (MRI/CT) is often prioritized to assess the extent of the tumor. * **Option D:** Approximately **80-90%** of parotid tumors originate in the **superficial lobe** (lateral to the facial nerve). Deep lobe involvement is much less common and may present as a parapharyngeal mass (dumbbell-shaped tumor). **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common benign tumor:** Pleomorphic Adenoma (all glands). * **Most common malignant tumor:** Mucoepidermoid Carcinoma (all glands). * **Warthin’s Tumor (Adenolymphoma):** Second most common benign parotid tumor; associated with smoking, often bilateral, and shows "hot spots" on Technetium-99m pertechnetate scan. * **Adenoid Cystic Carcinoma:** Known for **perineural invasion**, causing early pain and nerve palsies; has a "Swiss cheese" appearance on histology. * **Malignancy Rule:** The smaller the gland, the higher the chance of malignancy (Parotid ~20%, Submandibular ~40-50%, Sublingual/Minor ~80%).

Question 183: What is true of a carotid body tumor?

A. Non-chromaffin paraganglioma
B. Good prognosis
C. Rarely metastasizes
D. Similar to mixed parotid tumor (Correct Answer)

Explanation: ### **Explanation** The **Carotid Body Tumor (CBT)**, also known as a chemodectoma, is a rare neoplasm arising from the carotid body at the bifurcation of the common carotid artery. **Why Option D is Correct:** The comparison to a **mixed parotid tumor (pleomorphic adenoma)** is based on its **clinical presentation and anatomical location**, rather than its histology. Both tumors typically present as a slow-growing, painless, firm, and mobile lump in the upper neck/submandibular region. In clinical examinations, both exhibit a characteristic "sideways mobility" but are restricted vertically due to their attachments (CBT is fixed to the carotid bifurcation, while parotid tumors are limited by the stylomandibular ligament). **Analysis of Other Options:** * **Option A (Non-chromaffin paraganglioma):** This is actually a **TRUE** statement. CBTs are the most common non-chromaffin paragangliomas. However, in the context of standard surgical textbooks (like Bailey & Love), the comparison to mixed parotid tumors is a classic "textbook" description often tested in exams. * **Option B & C (Good prognosis / Rarely metastasizes):** These are also generally **TRUE**. Most CBTs are benign (approx. 90%) and have an excellent prognosis after surgical excision. *Note: In NEET-PG, when multiple statements are technically true, the "most characteristic" clinical description or the one explicitly mentioned in standard textbooks is preferred.* ### **High-Yield Clinical Pearls for NEET-PG:** * **Fontaine’s Sign:** The tumor can be moved horizontally but not vertically (due to its location within the carotid sheath). * **Lyre Sign:** On angiography, the tumor causes widening/splaying of the carotid bifurcation (displacement of internal and external carotid arteries). * **Histology:** Characterized by **Zellballen patterns** (clusters of chief cells surrounded by sustentacular cells). * **Origin:** Derived from **neural crest cells**; acts as a chemoreceptor sensitive to pH and $PaO_2$ changes. * **Shamblin Classification:** Used to grade the tumor based on its involvement/encasement of the carotid vessels.

Question 184: In a suspected neck injury, what is the initial assessment priority?

A. Assess for associated head injuries first.
B. Assess the neck first. (Correct Answer)
C. Assess the neck at the end of the primary survey.
D. Focus assessment solely on the hyoid bone in the neck.

Explanation: **Explanation:** In the management of trauma, particularly suspected neck injuries, the **Primary Survey (ABCDE)** dictates the sequence of care. However, in the specific context of a localized neck injury, the **neck must be assessed first** because it contains vital structures essential for life: the airway (larynx/trachea), major vascular channels (carotids/jugulars), and the cervical spine. Any compromise to these structures constitutes an immediate threat to life. * **Why Option B is correct:** The neck is the "bottleneck" of the body. An expanding hematoma or laryngeal fracture can lead to rapid airway obstruction. Therefore, immediate inspection for "Hard Signs" (e.g., active hemorrhage, bubbling wounds, expanding hematoma, or stridor) is the clinical priority to determine if emergency surgical intervention or airway management is required. * **Why Option A is wrong:** While head injuries are common comorbidities, the airway and vascular integrity (located in the neck) take precedence over neurological assessment (Disability) in the ABCDE sequence. * **Why Option C is wrong:** Waiting until the end of the primary survey is dangerous; the neck is evaluated during the 'A' (Airway with C-spine protection) and 'B' (Breathing) phases. * **Why Option D is wrong:** Assessment must be comprehensive, including the "Zones of the Neck" (I, II, and III), rather than focusing on a single bone. **High-Yield NEET-PG Pearls:** * **Hard Signs of Neck Injury:** Pulsatile bleeding, expanding hematoma, thrill/bruit, air bubbling from wound, and stridor. These mandate **immediate Neck Exploration**. * **Zone II** (between cricoid and angle of mandible) is the most commonly injured area. * **Platysma Rule:** Any wound penetrating the platysma muscle should never be probed in the ER; it requires surgical consultation and further imaging (CT Angiography) or exploration.

Question 185: Thyroglossal fistula develops due to what?

A. Developmental anomaly
B. Injury
C. Incomplete removal of thyroglossal cyst (Correct Answer)
D. Inflammatory disorder

Explanation: **Explanation:** A **thyroglossal fistula** is almost never a congenital (developmental) condition. Instead, it is an **acquired** condition that typically follows the rupture or surgical interference of a thyroglossal cyst. **Why Option C is correct:** The most common cause of a thyroglossal fistula is the **incomplete removal** of a thyroglossal cyst or its tract. If a surgeon fails to remove the entire tract (including the mid-portion of the hyoid bone), the remaining epithelial lining continues to secrete fluid, which eventually tracks to the skin surface, forming a fistula. It can also occur if a thyroglossal cyst becomes infected, forms an abscess, and bursts spontaneously or is simply incised and drained (I&D). **Why other options are incorrect:** * **A. Developmental anomaly:** While the *cyst* is developmental (due to persistent thyroglossal duct), the *fistula* is not present at birth. It is a secondary complication. * **B. Injury:** While trauma can occur, it is not the standard clinical etiology for these fistulae. * **D. Inflammatory disorder:** While infection (inflammation) often precedes the formation of a fistula, the underlying cause is the presence of the cyst/duct itself, not a primary inflammatory disease. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** The fistula is usually located in the midline of the neck, below the hyoid bone. * **Clinical Sign:** The fistula/cyst moves upward on **protrusion of the tongue** (due to its attachment to the hyoid bone and foramen caecum). * **Surgical Management:** The definitive treatment is the **Sistrunk Operation**. This involves excision of the cyst, the entire tract, and the **central part of the hyoid bone** to prevent recurrence. * **Lining:** It is lined by pseudostratified ciliated columnar epithelium.

Question 186: Radical dissection of the neck includes all of the following except:

A. Cervical lymph nodes
B. Sternocleidomastoid muscle
C. Phrenic nerves (Correct Answer)
D. Internal jugular vein

Explanation: The **Radical Neck Dissection (RND)**, originally described by Crile in 1906, is the gold standard surgical procedure for managing cervical lymph node metastasis. It involves the systematic removal of all lymph node groups from Level I to Level V on one side of the neck, along with three specific non-lymphatic structures. ### Why Phrenic Nerve is the Correct Answer: The **phrenic nerve** (C3-C5) lies deep to the prevertebral fascia on the anterior scalene muscle. In a standard RND, the surgical plane is superficial to the prevertebral fascia. Preserving the phrenic nerve is critical to maintain diaphragmatic function; its accidental resection leads to hemi-diaphragmatic paralysis. Therefore, it is **not** part of the radical dissection. ### Analysis of Incorrect Options: A Radical Neck Dissection specifically includes the removal of: * **Cervical Lymph Nodes (Option A):** All nodes in Levels I through V are removed. * **Sternocleidomastoid Muscle (Option B):** Removed to provide access to the deep cervical nodes and ensure oncological clearance. * **Internal Jugular Vein (Option D):** Removed as it is closely associated with the deep cervical chain (Level II, III, IV). * **Spinal Accessory Nerve (CN XI):** (Not listed in options but also removed in a classic RND). ### High-Yield Clinical Pearls for NEET-PG: * **Modified Radical Neck Dissection (MRND):** Removal of Level I-V nodes but **preservation** of one or more non-lymphatic structures (Type I: Preserves CN XI; Type II: Preserves CN XI + IJV; Type III: Preserves CN XI + IJV + SCM). * **Selective Neck Dissection (SND):** Preservation of one or more lymph node groups (e.g., Supraomohyoid dissection). * **Structures always preserved in RND:** Vagus nerve, Phrenic nerve, Brachial plexus, and Carotid artery.

Question 187: Which of the following statements about thoracic outlet syndrome is true?

A. The median nerve of the brachial plexus is commonly involved.
B. Surgical decompression of the brachial plexus is the best treatment. (Correct Answer)
C. It is often associated with cervical spine abnormalities.
D. Aortography can rule out the disease.

Explanation: **Explanation:** Thoracic Outlet Syndrome (TOS) refers to the compression of neurovascular structures (brachial plexus, subclavian artery, or subclavian vein) as they pass through the superior thoracic aperture. **1. Why Option B is Correct:** While initial management for most TOS cases is conservative (physical therapy), **surgical decompression** is considered the definitive and "best" treatment for patients with persistent symptoms, progressive neurological deficits, or vascular complications. Decompression typically involves **cervical rib resection, first rib resection, or scalenectomy** to create space for the brachial plexus. **2. Why the Other Options are Incorrect:** * **Option A:** The **lower trunk of the brachial plexus (C8-T1)** is the most commonly involved neural structure, leading to symptoms in the ulnar nerve distribution (not the median nerve). * **Option C:** TOS is primarily associated with **rib abnormalities** (e.g., cervical rib, elongated C7 transverse process) or muscular anomalies (scalenus anterior hypertrophy), rather than general cervical spine abnormalities like disc herniation. * **Option D:** Aortography is not the gold standard. While imaging (Duplex ultrasound, CT/MR angiography) helps diagnose vascular TOS, **Neurogenic TOS** (the most common type, >90%) is a clinical diagnosis often supported by EMG/Nerve conduction studies. **Clinical Pearls for NEET-PG:** * **Adson’s Test:** Loss of radial pulse when the patient rotates the head to the affected side and takes a deep breath (suggests scalene involvement). * **Roos Test (Elevated Arm Stress Test):** The most reliable clinical screening test for TOS. * **Gilliatt-Sumner Hand:** Wasting of the thenar and hypothenar eminence seen in chronic neurogenic TOS. * **Paget-Schroetter Syndrome:** Effort-induced thrombosis of the subclavian vein, a form of Venous TOS.

Question 188: Which of the following orthognathic surgeries involves a horizontal cut in the ramus?

A. Vertical Ramus Osteotomy (VRO)
B. Sagittal Split Ramus Osteotomy (SSRO) (Correct Answer)
C. Inverted L Osteotomy
D. Subapical Osteotomy

Explanation: **Explanation:** The **Sagittal Split Ramus Osteotomy (SSRO)** is the most versatile and commonly performed orthognathic procedure for correcting mandibular discrepancies (prognathism or retrognathism). The procedure involves three distinct bone cuts: 1. **Horizontal cut:** Made on the medial aspect of the ramus, superior to the mandibular foramen. 2. **Vertical cut:** Made on the lateral cortex, usually in the region of the second molar. 3. **Sagittal cut:** Connects the two, splitting the mandible into a tooth-bearing segment and a condyle-bearing segment. This allows for three-dimensional repositioning of the mandible. **Analysis of Incorrect Options:** * **Vertical Ramus Osteotomy (VRO):** This involves a vertical or slightly oblique cut from the sigmoid notch down to the lower border of the mandible. It is primarily used for mandibular setback and does not involve a horizontal ramus cut. * **Inverted L Osteotomy:** This involves a horizontal cut above the lingula followed by a vertical cut down to the inferior border. While it has a horizontal component, it is distinct from the "sagittal split" mechanism and is typically reserved for complex cases like hemifacial microsomia. * **Subapical Osteotomy:** This is a segmental surgery where the cut is made below the apices of the teeth (alveolar process) rather than in the ramus. It is used to move a specific segment of teeth and bone. **High-Yield Clinical Pearls for NEET-PG:** * **SSRO Advantage:** Provides excellent bone-to-bone contact, facilitating rapid healing and allowing for internal rigid fixation (no need for long-term intermaxillary fixation). * **Complication:** The most common complication of SSRO is **paresthesia of the lower lip** due to injury or traction on the Inferior Alveolar Nerve (IAN). * **Indication:** SSRO is the gold standard for **Mandibular Retrognathism** (advancement) and **Prognathism** (setback).

Question 189: In cleft lip operation, on which day are all the stitches typically removed?

A. 2nd day
B. 4th day (Correct Answer)
C. 7th day
D. 10th day

Explanation: **Explanation:** In cleft lip surgery (Cheiloplasty), the primary goal is to achieve an aesthetic result with minimal scarring. The timing of suture removal is critical to balance wound strength against the risk of permanent "track marks" or "railroad scarring." **Why 4th day is correct:** The facial skin has an excellent blood supply, which promotes rapid healing. Sutures in the facial region are typically removed early—usually between the **3rd and 5th postoperative days**. Removing them on the **4th day** provides sufficient time for the wound edges to adhere while preventing the epithelialization of the suture tracks, which causes permanent scarring. **Analysis of Incorrect Options:** * **2nd day:** This is too early. The tensile strength of the wound is insufficient at 48 hours, and there is a high risk of wound dehiscence (opening). * **7th day:** While common for abdominal or limb surgeries, 7 days is too long for the face. Leaving non-absorbable sutures for a week leads to prominent stitch marks and increased tissue reaction. * **10th day:** This is reserved for areas under high tension or with poor blood supply (e.g., over joints or the back). On the lip, this would result in significant cosmetic deformity. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of 10s (Millard’s Criteria):** Ideal time for cleft lip repair is when the infant is **10 weeks** old, weighs **10 pounds**, and has a hemoglobin of **10 g/dL**. * **Suture Material:** Usually 5-0 or 6-0 Monofilament (e.g., Nylon/Ethilon) or fast-absorbing gut. * **Cleft Palate Repair:** Typically performed between **6–12 months** of age (before the child develops significant speech patterns). * **Logan’s Bow:** A metal bow often taped to the cheeks after surgery to reduce tension on the suture line.

Question 190: Carotid body tumors arise from which type of cells?

A. This is not a tumor but is called a tumor.
B. Carotid artery.
C. Parasympathetic paraganglioma. (Correct Answer)
D. Sympathetic paraganglioma.

Explanation: **Explanation:** **Carotid body tumors (CBTs)**, also known as chemodectomas, are the most common type of head and neck paragangliomas. They originate from the **extra-adrenal neural crest cells** located at the bifurcation of the common carotid artery. 1. **Why Option C is correct:** Paragangliomas are classified into two types based on their location and function: * **Parasympathetic Paragangliomas:** These are primarily located in the head and neck (e.g., carotid body, glomus jugulare, glomus tympanicum). They are usually **non-functional** (do not secrete catecholamines). * **Sympathetic Paragangliomas:** These are located in the thorax, abdomen, or pelvis (e.g., Organ of Zuckerkandl) and are often functional (secrete catecholamines). Since the carotid body is a chemoreceptor organ associated with the parasympathetic system, its tumor is a **parasympathetic paraganglioma**. 2. **Why other options are incorrect:** * **Option A:** CBT is a true neoplasm, though it is usually benign (only 10% are malignant). * **Option B:** It arises from the paraganglia located *near* the artery, not from the arterial wall itself. * **Option D:** Sympathetic paragangliomas are typically found in the retroperitoneum and are functionally active, unlike CBTs. **High-Yield Clinical Pearls for NEET-PG:** * **Fontaine’s Sign:** The tumor is mobile horizontally but fixed vertically (due to its attachment to the carotid bifurcation). * **Lyre Sign:** On angiography, the tumor causes widening/splaying of the internal and external carotid arteries. * **Shamblin Classification:** Used to grade the tumor based on its involvement/encasement of the carotid vessels. * **Rule of 10:** Approximately 10% are bilateral, 10% are malignant, and 10% are familial (associated with SDH gene mutations).

Practice by Chapter

Salivary Gland Diseases

Practice Questions

Thyroid Gland Disorders

Practice Questions

Parathyroid Gland Disorders

Practice Questions

Neck Masses Evaluation

Practice Questions

Oral Cavity Lesions

Practice Questions

Laryngeal Disorders

Practice Questions

Head and Neck Cancer

Practice Questions

Reconstructive Techniques in Head and Neck Surgery

Practice Questions

Surgical Management of Sleep Apnea

Practice Questions

Airway Management in Head and Neck Surgery

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Surgical Approaches to the Neck

Practice Questions

Neck Dissection Techniques

Practice Questions

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