Head and Neck Surgery Practice Questions

Q: Structures preserved in modified radical neck dissection are all except:

Submandibular gland. ### Explanation The core concept behind neck dissections lies in the transition from the **Radical Neck Dissection (RND)** to the **Modified Radical Neck Dissection (MRND)**. In a **Radical Neck Dissection (Crile’s procedure)**, all lymph nodes from levels I to V are removed along with three non-lymphatic structures: the Spinal Accessory Nerve (SAN), the Sternocleidomastoid (SCM) muscle, and the Internal Jugular Vein (IJV). **Modified Radical Neck Dissection (MRND)** was developed to reduce morbidity by preserving one or more of these non-lymphatic structures. * **Why Option C is correct:** The **Submandibular gland** is part of the Level Ib nodal compartment. In both RND and MRND, the submandibular gland is **routinely removed** to ensure complete clearance of the Level I lymph nodes. It is not considered a "preserved structure" in the definition of MRND. * **Why Options A, B, and D are incorrect:** These are the three specific structures that define the "Modified" types: * **MRND Type I:** Preserves the Spinal Accessory Nerve. * **MRND Type II:** Preserves the Spinal Accessory Nerve and the Internal Jugular Vein. * **MRND Type III (Functional Neck Dissection):** Preserves all three—SAN, IJV, and SCM. ### High-Yield Clinical Pearls for NEET-PG: 1. **Selective Neck Dissection (SND):** Unlike MRND (which removes levels I-V), SND preserves one or more lymph node levels (e.g., Supraomohyoid dissection removes only levels I-III). 2. **Most commonly preserved structure:** The Spinal Accessory Nerve (to prevent "Shoulder Syndrome" or shoulder drop). 3. **Boundary of Level II and III:** The bifurcation of the carotid artery or the hyoid bone. 4. **Level VI:** Refers to the anterior compartment (pre-tracheal, para-tracheal nodes), often cleared in thyroid malignancies.

Q: What is the treatment for a child with cherubism?

Cosmetic surgery after puberty. **Explanation:** **Cherubism** is a rare, autosomal dominant fibro-osseous disorder characterized by symmetrical, non-neoplastic enlargement of the mandible and maxilla. It is caused by a mutation in the **SH3BP2 gene**. **Why Option B is Correct:** The natural history of cherubism is unique: the lesions typically appear in early childhood (2–7 years), progress until puberty, and then undergo **spontaneous regression** or stabilization as the fibrous tissue undergoes remodeling into normal bone. Therefore, the standard management is **observation**. Surgical intervention is deferred until after puberty to allow for natural regression. If significant deformity persists after skeletal maturity, **cosmetic contouring** (recontouring of the bone) is performed. **Why Other Options are Incorrect:** * **A & D (Surgical excision/En bloc dissection):** Aggressive surgery during the active growth phase is contraindicated as it can trigger rapid regrowth or cause severe dental and facial developmental issues. Surgery is only indicated earlier if there is functional impairment (e.g., airway obstruction or severe visual loss). * **C (Radiation):** Radiation therapy is strictly contraindicated due to the high risk of secondary osteosarcoma and interference with facial growth. **NEET-PG High-Yield Pearls:** * **Radiology:** Characterized by **bilateral, symmetrical multilocular radiolucencies** (soap-bubble appearance) at the angles of the mandible. * **Clinical Feature:** "Eyes upturned to heaven" sign (due to maxillary involvement stretching the skin and exposing the lower sclera). * **Histology:** Features giant cells similar to Giant Cell Granuloma. * **Inheritance:** Autosomal Dominant (SH3BP2 gene on chromosome 4p16).

Q: When should a surgical obturator be inserted?

On the day of the surgery. ### Explanation In maxillofacial surgery, particularly for maxillectomy procedures, a **surgical obturator** is a prosthetic device used to seal the defect created between the oral and nasal/antral cavities. **Why Option B is Correct:** The surgical obturator is inserted **intraoperatively (on the day of the surgery)** immediately after the resection is completed. The primary objectives are: 1. **Immediate Function:** It allows the patient to speak and swallow (deglutition) immediately post-op without nasal regurgitation. 2. **Wound Protection:** It supports the surgical packing and protects the raw wound/skin graft from oral fluids and bacterial contamination. 3. **Psychological Benefit:** It minimizes the immediate trauma of losing a large portion of the palate or midface. **Analysis of Incorrect Options:** * **Option A (One day prior):** Inserting the device before surgery is impossible as the defect has not yet been created, and the device would interfere with intubation and the surgical site. * **Option C & D (14 or 30 days after):** Waiting weeks to insert an obturator would lead to severe speech impairment, inability to eat orally, and significant wound contraction/scarring, making future prosthetic fitting much more difficult. **High-Yield Clinical Pearls for NEET-PG:** * **Sequence of Obturators:** 1. **Surgical Obturator:** Inserted on Day 0; worn for 7–10 days. 2. **Interim/Delayed Obturator:** Inserted after the removal of surgical packing (approx. 2 weeks post-op) during the healing phase. 3. **Definitive Obturator:** Inserted only after complete wound healing and remodeling (usually **3–6 months** post-surgery). * **Retention:** The surgical obturator is often secured to remaining teeth or fixed to the alveolar bone/nasal spine using wires or screws. * **Material:** Usually made of clear acrylic to allow the surgeon to visualize any pressure points or ischemia on the underlying tissues.

Q: Commando’s operation is indicated for which condition?

Oral cancer. **Explanation:** **Commando’s Operation** (Combined Mandibulectomy and Neck Dissection Operation) is a major surgical procedure primarily indicated for **advanced oral cavity cancers**, particularly those involving the tongue, floor of the mouth, or lower alveolus where the tumor has invaded or is in close proximity to the mandible. 1. **Why it is correct:** The term "Commando" was coined during WWII (referring to the toughness of the surgery and the soldiers). It involves a **tri-partite approach**: * Resection of the primary intra-oral lesion. * Partial or total **mandibulectomy** (removal of the jawbone). * **Radical Neck Dissection (RND)** to remove cervical lymph node metastases. This aggressive approach ensures oncological clearance for tumors that bridge the oral mucosa and the bone. 2. **Why incorrect options are wrong:** * **Radical Mastectomy:** This is the Halsted procedure, involving removal of the breast, pectoralis muscles, and axillary lymph nodes. * **Mandible Fracture:** These are managed via Open Reduction and Internal Fixation (ORIF) or closed reduction, not radical resection. * **Leg Amputation:** These are orthopedic/vascular procedures (e.g., Below-Knee or Above-Knee amputation) unrelated to head and neck oncology. **Clinical Pearls for NEET-PG:** * **Composite Resection:** Another name for Commando’s operation when the primary tumor, bone, and lymph nodes are removed in continuity. * **Reconstruction:** Nowadays, "Commando" is often followed by microvascular free flap reconstruction (e.g., **Fibula free flap**) to restore form and function. * **Indication:** Specifically indicated when the tumor is fixed to the mandible or shows radiological evidence of cortical bone invasion.

Q: What is the standard treatment for stage T3N1 carcinoma of the maxilla?

Surgery and radiation. **Explanation:** The management of maxillary sinus carcinoma is determined by the clinical stage. **Stage T3N1** represents advanced local disease (T3: invasion of the posterior wall, floor/medial wall of the orbit, or ethmoid sinus) with regional lymph node involvement (N1). 1. **Why Option B is correct:** For advanced-stage (Stage III and IV) squamous cell carcinoma of the maxilla, the standard of care is **multimodal therapy**. Surgery (typically a total or extended maxillectomy) followed by **adjuvant radiotherapy** is the gold standard. Post-operative radiation is mandatory in T3/T4 tumors or when nodal disease (N1) is present to improve local control and address potential microscopic residual disease. 2. **Why other options are incorrect:** * **Option A (Surgery only):** This is reserved for very early, localized T1 or T2 tumors with no nodal involvement. In T3N1, the risk of recurrence is unacceptably high with surgery alone. * **Option B (Radiation only):** Radiation alone has poor cure rates for bone-invasive maxillary tumors and is generally reserved for palliative cases or patients unfit for surgery. * **Option D (Chemoradiation):** While definitive chemoradiation is common in oropharyngeal or laryngeal cancers, in maxillary sinus tumors, surgical resection remains the primary treatment modality whenever the tumor is resectable. **Clinical Pearls for NEET-PG:** * **Ohngren’s Line:** An imaginary line connecting the medial canthus to the angle of the mandible. Tumors **posterosuperior** to this line have a worse prognosis. * **Most common histology:** Squamous cell carcinoma (80%). * **Lymphatic drainage:** Primarily to the submandibular and deep cervical nodes. * **Infrastructure vs. Suprastructure:** Tumors of the infrastructure (below the level of the maxillary sinus floor) have a better prognosis than those of the suprastructure.

Q: Pleomorphic adenoma is most commonly found in which salivary gland?

Parotid gland. **Explanation:** **Pleomorphic Adenoma (Benign Mixed Tumor)** is the most common salivary gland tumor, accounting for approximately 60–70% of all salivary gland neoplasms. 1. **Why Parotid Gland is Correct:** The **Parotid gland** is the most frequent site for both salivary gland tumors in general and Pleomorphic Adenoma specifically. About 80% of all salivary gland tumors occur in the parotid, and 80% of those are Pleomorphic Adenomas. It typically presents as a slow-growing, painless, firm swelling at the angle of the jaw, most commonly involving the superficial lobe. 2. **Why Other Options are Incorrect:** * **Submandibular Gland:** Only about 10% of salivary tumors occur here. While Pleomorphic Adenoma is still the most common benign tumor of this gland, its overall incidence is much lower than in the parotid. * **Sublingual Gland:** Tumors here are rare (approx. 1%). Notably, a tumor in the sublingual gland has an 80% chance of being **malignant** (e.g., Adenoid Cystic Carcinoma). * **Lacrimal Gland:** While Pleomorphic Adenoma can occur in the lacrimal gland (the most common epithelial tumor there), it is far less frequent than in the major salivary glands. **Clinical Pearls for NEET-PG:** * **Rule of 80s:** 80% of salivary tumors are in the Parotid; 80% of Parotid tumors are Pleomorphic Adenoma; 80% occur in the superficial lobe. * **Histology:** Characterized by a "mixed" appearance—epithelial elements (ducts/acini) and mesenchymal-like stroma (myxoid, chondroid, or osteoid). * **Treatment:** Superficial parotidectomy with preservation of the **Facial Nerve**. Simple enucleation is avoided due to the risk of recurrence from "pseudopods" (microscopic projections through the capsule). * **Malignant Transformation:** Long-standing cases can transform into **Carcinoma ex pleomorphic adenoma**.

Question 1

Structures preserved in modified radical neck dissection are all except:

Accepted Answer

Submandibular gland

Answer

Accessory nerve

Answer

Sternocleidomastoid muscle

Answer

Internal jugular vein

Question 2

What is the treatment for a child with cherubism?

Accepted Answer

Cosmetic surgery after puberty

Answer

Surgical excision

Answer

Radiation

Answer

En bloc dissection

Question 3

When should a surgical obturator be inserted?

Accepted Answer

On the day of the surgery

Answer

One day prior to the surgery

Answer

14 days after the surgery

Answer

30 days after the surgery

Question 4

Frey's syndrome is caused by which of the following nerve interactions?

Accepted Answer

Post-traumatic connection between facial nerve fibers and parasympathetic fibers of the auriculotemporal nerve.

Answer

Connection between the greater auricular nerve and the auriculotemporal nerve.

Answer

Connection between the facial nerve and the greater auricular nerve.

Answer

None of the above.

Question 5

A patient presents with a tumor at the base of the tongue. What is the treatment of choice?

Accepted Answer

Wide local excision plus cervical lymph node dissection

Answer

Wide local excision

Answer

Wide local excision plus radiotherapy

Answer

Hemiglossectomy

Question 6

Commando’s operation is indicated for which condition?

Accepted Answer

Oral cancer

Answer

Radical mastectomy

Answer

Mandible fracture

Answer

Leg amputation

Question 7

What is the standard treatment for stage T3N1 carcinoma of the maxilla?

Accepted Answer

Surgery and radiation

Answer

Surgery only

Answer

Radiation therapy only

Answer

Chemotherapy and radiation

Question 8

Pleomorphic adenoma is most commonly found in which salivary gland?

Accepted Answer

Parotid gland

Answer

Sublingual gland

Answer

Submandibular gland

Answer

Lacrimal gland

Question 9

All of the following are common sites of a berry aneurysm, EXCEPT:

Accepted Answer

Vertebral artery

Answer

Posterior cerebral artery

Answer

Anterior cerebral artery

Answer

Middle cerebral artery

Question 10

In extended supraomohyoid neck dissection, lymph node dissection is done up to which level?

Accepted Answer

Level IV

Answer

Level II

Answer

Level III

Answer

Level V

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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