Head and Neck Surgery Practice Questions

Q: Sistrunk operation is used for the treatment of:

Thyroglossal duct cyst. **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**.

Q: What is true about tumors of the salivary glands?

The most common site is the parotid gland.. ### 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%).

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

Assess the neck first.. **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.

Q: Thyroglossal fistula develops due to what?

Incomplete removal of thyroglossal cyst. **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.

Q: Radical dissection of the neck includes all of the following except:

Phrenic nerves. 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.

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

Sagittal Split Ramus Osteotomy (SSRO). **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).

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

4th day. **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.

Q: Carotid body tumors arise from which type of cells?

Parasympathetic paraganglioma.. **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).

Question 1

Sistrunk operation is used for the treatment of:

Accepted Answer

Thyroglossal duct cyst

Answer

Pharyngeal pouch

Answer

Cystic hygroma

Answer

Sternocleidomastoid tumor

Question 2

What is true about tumors of the salivary glands?

Accepted Answer

The most common site is the parotid gland.

Answer

Enucleation is the treatment of choice.

Answer

Fine Needle Aspiration Cytology (FNAC) is mandatory.

Answer

The most common site of origin is the deep lobe.

Question 3

What is true of a carotid body tumor?

Accepted Answer

Similar to mixed parotid tumor

Answer

Non-chromaffin paraganglioma

Answer

Good prognosis

Answer

Rarely metastasizes

Question 4

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

Accepted Answer

Assess the neck first.

Answer

Assess for associated head injuries first.

Answer

Assess the neck at the end of the primary survey.

Answer

Focus assessment solely on the hyoid bone in the neck.

Question 5

Thyroglossal fistula develops due to what?

Accepted Answer

Incomplete removal of thyroglossal cyst

Answer

Developmental anomaly

Answer

Injury

Answer

Inflammatory disorder

Question 6

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

Accepted Answer

Phrenic nerves

Answer

Cervical lymph nodes

Answer

Sternocleidomastoid muscle

Answer

Internal jugular vein

Question 7

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

Accepted Answer

Surgical decompression of the brachial plexus is the best treatment.

Answer

The median nerve of the brachial plexus is commonly involved.

Answer

It is often associated with cervical spine abnormalities.

Answer

Aortography can rule out the disease.

Question 8

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

Accepted Answer

Sagittal Split Ramus Osteotomy (SSRO)

Answer

Vertical Ramus Osteotomy (VRO)

Answer

Inverted L Osteotomy

Answer

Subapical Osteotomy

Question 9

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

Accepted Answer

4th day

Answer

2nd day

Answer

7th day

Answer

10th day

Question 10

Carotid body tumors arise from which type of cells?

Accepted Answer

Parasympathetic paraganglioma.

Answer

This is not a tumor but is called a tumor.

Answer

Carotid artery.

Answer

Sympathetic paraganglioma.

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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