Head and Neck Surgery Practice Questions

Q: An absolute contraindication for extraction of teeth is:

Central hemangioma. **Explanation:** The correct answer is **Central Hemangioma**. **Why Central Hemangioma is the Correct Answer:** A central hemangioma is a benign vascular neoplasm located within the bone (usually the mandible). It consists of a proliferation of blood vessels that create large, blood-filled cavernous spaces. Tooth extraction in the vicinity of a central hemangioma is an **absolute contraindication** because it can lead to sudden, massive, and often uncontrollable "exsanguinating" hemorrhage. Once the tooth is removed, the protective bony socket is lost, and the high-pressure vascular lesion can bleed so rapidly that it may result in hypovolemic shock or death on the dental chair. **Why Other Options are Incorrect:** * **Hypertension:** This is a **relative contraindication**. Extraction can be performed once blood pressure is pharmacologically controlled (usually <160/100 mmHg) and with the use of local anesthesia containing limited epinephrine. * **Myocardial Infarction (MI):** This is a **relative contraindication**. Elective extractions are typically deferred for 6 months post-MI to allow the myocardium to heal and to manage anticoagulant therapy. However, it is not "absolute" in emergency life-saving situations. * **Thyrotoxicosis:** This is a **relative contraindication**. Uncontrolled hyperthyroidism carries a risk of "Thyroid Storm" due to stress; however, once the patient is rendered euthyroid with medication, extraction is safe. **High-Yield Clinical Pearls for NEET-PG:** * **Radiographic Appearance:** Central hemangiomas often show a "soap bubble," "honeycomb," or "sunburst" appearance on X-ray. * **Aspiration Test:** Always perform needle aspiration before any surgical intervention in a suspected bony lesion of the jaw to rule out a vascular malformation. * **Management:** Treatment of central hemangioma usually involves embolization followed by surgical resection or sclerotherapy.

Q: Which salivary gland tumor is exclusively seen in the parotid gland?

Warthin's tumor. **Explanation:** **Warthin’s Tumor (Papillary Cystadenoma Lymphomatosum)** is the correct answer because of its unique embryological origin. During development, the parotid gland is the only salivary gland that contains **intraparenchymal lymph nodes**. Warthin’s tumor arises from salivary ductal epithelium that becomes entrapped within these lymphoid tissues during fetal life. Since other salivary glands (submandibular, sublingual, or minor) do not contain these internal lymph nodes, Warthin’s tumor is found **exclusively in the parotid gland** (specifically the tail of the parotid). **Analysis of Incorrect Options:** * **Pleomorphic Adenoma:** This is the most common salivary gland tumor overall. While it most frequently occurs in the parotid, it can arise in any salivary gland, including the submandibular and minor salivary glands (most commonly the palate). * **Mucoepidermoid Carcinoma:** This is the most common malignant salivary gland tumor. It occurs in both major and minor salivary glands. * **Adenoid Cystic Carcinoma:** This is the most common malignant tumor of the **submandibular and minor salivary glands**. It is notorious for perineural invasion. **High-Yield NEET-PG Pearls:** * **Smoking Link:** Warthin’s tumor is strongly associated with smoking. * **Hot Spot:** On Technetium-99m pertechnetate scan, Warthin’s tumor appears as a "hot" lesion (due to the presence of oncocytes). * **Bilateralism:** It is the most common salivary tumor to present bilaterally or multicentrically (10% of cases). * **Demographics:** Classically seen in older males (though the male-to-female ratio is narrowing).

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: A 3 cm squamous cell carcinoma of the retrornolar trigone is invading the mandible and the medial pterygoid muscle. What is the TNM stage of this tumor?

Stage IV. ### Explanation The TNM staging for Oral Cavity cancers (including the retromolar trigone) is based on the size and depth of invasion (T), nodal involvement (N), and metastasis (M). **1. Why Stage IV is Correct:** According to the AJCC 8th Edition, the T-stage is determined by the extent of local invasion. * **T4a (Moderately Advanced Local Disease):** The tumor invades adjacent structures such as the cortical bone of the mandible or maxilla, deep (extrinsic) muscles of the tongue, maxillary sinus, or skin of the face. * **T4b (Very Advanced Local Disease):** The tumor invades the masticator space (which includes the **medial pterygoid muscle**), pterygoid plates, or skull base, and/or encases the internal carotid artery. In this case, invasion into the **medial pterygoid muscle** automatically classifies the tumor as **T4b**. Any T4 tumor (T4a or T4b) with any N or M status results in a **Stage IV** designation (specifically Stage IVB for T4b). **2. Why Other Options are Incorrect:** * **Stage I:** Requires a T1 tumor (≤2 cm and Depth of Invasion [DOI] ≤5 mm) with no nodal involvement. * **Stage II:** Requires a T2 tumor (>2 cm and ≤4 cm, DOI ≤10 mm) with no nodal involvement. * **Stage III:** Requires a T3 tumor (>4 cm or DOI >10 mm) or a T1/T2/T3 tumor with a single ipsilateral lymph node ≤3 cm (N1). **3. Clinical Pearls for NEET-PG:** * **Retromolar Trigone (RMT):** A unique site where the mucosa is closely attached to the bone; hence, early bone invasion is common. * **Masticator Space:** Involvement of the medial pterygoid often presents clinically as **trismus** (lockjaw), which is a "red flag" for T4b disease. * **Bone Invasion:** Superficial erosion of bone/tooth socket by a gingival primary is not enough to classify as T4; there must be invasion through the cortical bone.

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**.

Q: What is the name of the incision shown below?

Weber-Ferguson incision. ***Weber-Ferguson incision*** - A **lip-split incision** that extends from the **philtrum** through the **alar base** and along the **infraorbital rim**, providing excellent exposure for **maxillectomy** procedures. - Specifically designed for **total maxillectomy** and **rhinectomy**, allowing wide access to the **maxillary sinus** and **nasal cavity** while maintaining good cosmetic outcomes. *Lazy 'S' incision* - A **parotidectomy incision** that follows a curved **S-shaped** path from the **preauricular** area to the **neck**, used specifically for **parotid gland** surgery. - Does not involve **lip-splitting** or **facial extension** like the Weber-Ferguson, making it unsuitable for **maxillary** procedures. *Sistrunk incision* - A **horizontal neck incision** used specifically for **thyroglossal duct cyst** excision, located over the **hyoid bone** level. - Does not provide any **facial** or **maxillary** access, being limited to **central neck** pathology only. *Modified Blair's* - A **parotidectomy incision** that extends from the **preauricular** area around the **ear lobule** into the **neck**, used for **parotid gland** procedures. - Like the Lazy S, it's designed for **parotid surgery** and does not involve **midface** or **maxillary** exposure.

Q: A 58-year-old woman undergoes excision biopsy of a tumor in the left posterior triangle of her neck. Histology suggests that this is a metastatic cancer. What is the most likely site of the primary tumor?

Piriform fossa. **Explanation:** The clinical presentation of a metastatic lymph node in the **posterior triangle** (Level V) of the neck in an adult most commonly points to a primary malignancy within the **Upper Aerodigestive Tract (UADT)**. **1. Why Piriform Fossa is Correct:** The piriform fossa is a part of the hypopharynx. Tumors in this region are notorious for being "clinically silent" in their early stages while having a rich lymphatic network. Consequently, they often present first as a metastatic neck mass. While Level II and III nodes are more common, hypopharyngeal and nasopharyngeal carcinomas are the most frequent primary sources for metastases found in the **posterior triangle (Level V)**. **2. Why Incorrect Options are Wrong:** * **Ovary, Adrenal Gland, and Kidney:** These are infraclavicular (below the diaphragm) organs. While they can metastasize to the neck, they typically involve the **Supraclavicular nodes** (specifically the left supraclavicular node, known as **Virchow’s node** or Troisier’s sign) via the thoracic duct. They do not typically present as isolated posterior triangle masses. **3. NEET-PG High-Yield Pearls:** * **Rule of 80:** In a non-thyroid neck mass in an adult, 80% are neoplastic; of those, 80% are malignant; of those, 80% are metastatic; and of those, 80% arise from primaries above the clavicle. * **Levels of Neck Nodes:** * **Level V (Posterior Triangle):** Think Nasopharynx, Hypopharynx, or Scalp. * **Level II (Upper Jugular):** Think Oral cavity, Oropharynx. * **Silent Areas:** Always check the "blind spots" (Nasopharynx, Tonsil, Base of tongue, and Piriform fossa) in any case of occult primary neck metastasis.

Q: The Berger flap procedure is used for which of the following conditions?

Oro-antral communication. **Explanation:** The **Berger flap** (also known as the buccal fat pad flap or the sliding buccal flap) is a classic surgical technique used for the closure of an **Oro-antral communication (OAC)** or fistula. 1. **Why it is correct:** An OAC is an abnormal opening between the maxillary sinus and the oral cavity, commonly occurring after the extraction of maxillary molars. The Berger flap involves a trapezoidal, full-thickness mucoperiosteal flap raised from the buccal vestibule and advanced over the defect. Because the buccal mucosa is elastic, it can be "slid" and sutured to the palatal mucosa to create a tension-free primary closure. 2. **Why other options are incorrect:** * **TMJ Ankylosis:** This condition requires arthroplasty (gap or interpositional) using materials like temporal fascia or costochondral grafts, not a buccal mucosal flap. * **TMJ Dislocation:** Acute cases are managed by manual reduction (Hippocratic maneuver); chronic cases may require eminectomy or capsular plication. * **Pericoronitis:** This is an inflammation of the tissue surrounding a partially erupted tooth (usually the third molar) and is managed with irrigation, antibiotics, or operculectomy. **High-Yield Clinical Pearls for NEET-PG:** * **Rehrmann’s Flap:** Another name for the buccal advancement flap used for OAC closure. * **Gold Standard:** For defects larger than 5mm or those persisting for more than 48 hours, surgical closure (like the Berger flap) is mandatory. * **Buccal Fat Pad (BFP):** Often used in conjunction with the Berger flap (double-layered closure) because the BFP is highly vascular and promotes rapid healing. * **Post-op instruction:** Patients must avoid sneezing with a closed mouth or using a straw to prevent pressure changes that could dehisce the flap.

Question 1

An absolute contraindication for extraction of teeth is:

Accepted Answer

Central hemangioma

Answer

Hypertension

Answer

Myocardial infarction

Answer

Thyrotoxicosis

Question 2

Which salivary gland tumor is exclusively seen in the parotid gland?

Accepted Answer

Warthin's tumor

Answer

Pleomorphic adenoma

Answer

Mucoepidermoid carcinoma

Answer

Adenoid cystic carcinoma

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

A 3 cm squamous cell carcinoma of the retrornolar trigone is invading the mandible and the medial pterygoid muscle. What is the TNM stage of this tumor?

Accepted Answer

Stage IV

Answer

Stage I

Answer

Stage II

Answer

Stage III

Question 5

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 6

Pleomorphic adenoma is most commonly found in which salivary gland?

Accepted Answer

Parotid gland

Answer

Sublingual gland

Answer

Submandibular gland

Answer

Lacrimal gland

Question 7

Facial nerve injury occurs during parotid surgery. What is the best management?

Accepted Answer

Immediate repair

Answer

Repair at a later date

Answer

Physiotherapy

Answer

No intervention

Question 8

What is the name of the incision shown below?

Accepted Answer

Weber-Ferguson incision

Answer

Lazy 'S' incision

Answer

Sistrunk incision

Answer

Modified Blair's

Question 9

A 58-year-old woman undergoes excision biopsy of a tumor in the left posterior triangle of her neck. Histology suggests that this is a metastatic cancer. What is the most likely site of the primary tumor?

Accepted Answer

Piriform fossa

Answer

Ovary

Answer

Adrenal gland

Answer

Kidney

Question 10

The Berger flap procedure is used for which of the following conditions?

Accepted Answer

Oro-antral communication

Answer

Temporomandibular joint (TMJ) ankylosis

Answer

Temporomandibular joint (TMJ) dislocation

Answer

Pericoronitis

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?