Head and Neck Surgery Practice Questions

Q: Modified radical neck dissection includes which of the following?

Levels I-V. ### Explanation **Concept Overview:** Neck dissections are classified based on the lymph node levels removed and the preservation of non-lymphatic structures. A **Radical Neck Dissection (RND)** involves the removal of lymph node **Levels I through V**, along with three key structures: the Sternocleidomastoid muscle (SCM), the Internal Jugular Vein (IJV), and the Spinal Accessory Nerve (SAN). **Why Option D is Correct:** A **Modified Radical Neck Dissection (MRND)** also involves the systematic removal of lymph node **Levels I-V** (the same nodal footprint as RND). The "Modified" aspect refers to the **preservation** of one or more of the three non-lymphatic structures (SAN, IJV, or SCM). Since the question asks what levels are included, Levels I-V is the standard anatomical boundary for both RND and MRND. **Analysis of Incorrect Options:** * **Option A (Levels I-IV):** This typically describes a *Supraomohyoid* neck dissection (a type of Selective Neck Dissection) often used in oral cavity cancers, but it omits Level V (posterior triangle). * **Option B (Levels I-VII):** Level VI (central compartment) and Level VII (superior mediastinal) are not part of a standard MRND; they are addressed in thyroid or esophageal malignancies. * **Option C (Levels I-III):** This is a *Selective Neck Dissection* (Supraomohyoid) often performed for N0 necks in oral cavity squamous cell carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **MRND Types:** * **Type I:** SAN preserved. * **Type II:** SAN and IJV preserved. * **Type III (Functional Neck Dissection):** SAN, IJV, and SCM all preserved. * **Boundary of Level V:** Defined by the posterior border of the SCM (anteriorly), the anterior border of the Trapezius (posteriorly), and the Clavicle (inferiorly). * **Most common nerve injured** during neck dissection leading to shoulder drop: **Spinal Accessory Nerve.**

Q: A potato tumor is a tumor of which of the following structures?

Carotid body. **Explanation:** The term **"Potato Tumor"** is a classic clinical eponym for a **Carotid Body Tumor (Chemodectoma)**. **1. Why Carotid Body is Correct:** The carotid body is a chemoreceptor located at the bifurcation of the common carotid artery. A tumor arising from the paraganglion cells here is highly vascular and slow-growing. It is called a "potato tumor" because of its characteristic **firm, oval, and lobulated appearance**, which resembles a potato. Clinically, it presents as a painless neck mass that is **mobile horizontally but fixed vertically** (Fontaine’s Sign), as it is tethered to the carotid bifurcation. **2. Why Incorrect Options are Wrong:** * **Sternocleidomastoid muscle:** Tumors of this muscle (like a fibromatosis colli or "sternomastoid tumor of infancy") are associated with torticollis, not the "potato tumor" morphology. * **Carotid sinus:** The carotid sinus is a baroreceptor (pressure sensor) located in the adventitia of the carotid artery. While anatomically adjacent to the carotid body, it is a physiological structure, not the tissue of origin for this specific neoplasm. **3. High-Yield Clinical Pearls for NEET-PG:** * **Lyre Sign:** On angiography, the tumor causes characteristic widening/splaying of the carotid bifurcation (displacement of internal and external carotid arteries). * **Shamblin Classification:** Used to grade the tumor based on its involvement/encasement of the carotid vessels. * **Histology:** Features a **"Zellballen" pattern** (nests of chief cells surrounded by sustentacular cells). * **Rule of 10s:** Approximately 10% are bilateral, 10% are familial, and 10% are malignant. * **Treatment:** Surgical excision is the mainstay; preoperative embolization may be used to reduce vascularity.

Q: Which of the following is NOT true for carcinoma of the tongue?

Adenocarcinoma is the commonest type. **Explanation:** The correct answer is **B**, as **Squamous Cell Carcinoma (SCC)**—not adenocarcinoma—is the most common histological type of tongue cancer, accounting for over 90% of cases. Adenocarcinomas are rare and typically arise from minor salivary glands within the oral cavity. **Analysis of Options:** * **Option A (Lateral border):** This is the most frequent site for tongue carcinoma (especially the middle third). The dorsum is rarely involved, and the tip/ventral surface are less common. * **Option C (Lymph node involvement):** The tongue has a rich, decussating lymphatic network. Early lymphatic spread to the cervical nodes (specifically Level II/Jugulodigastric) is a hallmark of this disease, often occurring even in early stages. * **Option D (Tobacco chewing):** Chronic irritation from tobacco (chewing or smoking), betel nut, and alcohol are the primary synergistic risk factors for oral SCC. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Oral Cavity Cancer:** Lower lip (globally), but in India, it is the **buccal mucosa** (due to tobacco chewing). * **Premalignant lesions:** Leukoplakia (most common) and Erythroplakia (highest risk of transformation). * **Staging Tip:** Tongue cancers are staged based on size (T) and depth of invasion (DOI). A DOI > 5mm significantly increases the risk of nodal metastasis. * **Management:** Surgery is the primary treatment. For N0 necks, elective neck dissection is often performed if the tumor thickness exceeds 4mm.

Q: A midline swelling is seen in all except:

Branchial cyst. **Explanation:** The key to solving midline neck swelling questions lies in understanding the embryological origins of neck structures. **Why Branchial Cyst is the correct answer:** A **Branchial Cyst** (specifically from the second branchial cleft, which accounts for 95% of cases) is characteristically a **lateral neck swelling**. It is typically located at the junction of the upper third and middle third of the sternocleidomastoid muscle, along its anterior border. Because it arises from the failure of the cervical sinus of His to obliterate, it is anatomically sequestered to the side of the neck and does **not** occur in the midline. **Analysis of Incorrect Options (Midline Swellings):** * **Thyroglossal Cyst:** The most common congenital midline swelling. It develops along the path of the descending thyroid gland (from the foramen caecum to the thyroid isthmus). A classic sign is that it moves upward on protrusion of the tongue. * **Submental Lymphadenopathy:** These nodes are located in the submental triangle, bounded by the anterior bellies of the digastric muscles and the hyoid bone, placing them directly in the midline under the chin. * **Substernal Cyst (Dermoid Cyst):** Often referred to in this context as a submental or suprasternal dermoid cyst, these are sequestration dermoids that occur at lines of embryonic fusion, frequently presenting as painless midline masses. **NEET-PG High-Yield Pearls:** 1. **Movement with Deglutition:** Both Thyroglossal cysts and Thyroid swellings move with swallowing, but **only** Thyroglossal cysts move with tongue protrusion. 2. **Branchial Fistula:** The internal opening is usually in the tonsillar fossa; the external opening is in the lower third of the neck. 3. **Ranula:** A cystic swelling in the floor of the mouth (plunging ranula can present in the neck), usually lateral to the midline.

Q: What is the principal purpose of an acrylic splint in surgical procedures?

To prevent hematoma formation. **Explanation:** The principal purpose of an acrylic splint in surgical procedures, particularly in oral and maxillofacial surgery (such as palatal surgery or skin grafting), is to **prevent hematoma formation**. **1. Why Option A is Correct:** After procedures like the excision of a torus palatinus or palatal flap surgery, a potential space is created between the soft tissue and the underlying bone. Blood can accumulate in this space, leading to a hematoma, which may cause flap necrosis or infection. An acrylic splint acts as a **pressure dressing**, closely adapting the soft tissue flap to the bone. This eliminates dead space and provides continuous compression, which is the most effective way to prevent hematoma formation. **2. Why Other Options are Incorrect:** * **Option B (Dry Socket):** Dry socket (Alveolar Osteitis) is primarily prevented by atraumatic extraction techniques, avoiding smoking, and maintaining the integrity of the initial blood clot. While splints protect surgical sites, they are not the standard treatment or preventive measure for dry socket. * **Option C (Infection):** While preventing a hematoma indirectly reduces the risk of secondary infection (as hematomas act as culture media), the *primary* mechanical function of the splint is compression, not antisepsis or antimicrobial action. **Clinical Pearls for NEET-PG:** * **Dead Space Management:** In surgery, "dead space" is the enemy of healing. Acrylic splints are the intraoral equivalent of a pressure bandage used elsewhere on the body. * **Skin Grafts:** When placing a skin graft in the oral cavity (e.g., vestibuloplasty), an acrylic splint is essential to keep the graft immobilized and in firm contact with the recipient bed. * **Torus Palatinus:** Post-operative splints are mandatory after removing a large palatal torus to prevent the heavy palatal flap from sagging and forming a large clot.

Q: Which incision is used for modified radical neck dissection?

Macfee incision. **Explanation:** The **MacFee incision** is the preferred choice for neck dissections, including Modified Radical Neck Dissection (MRND), particularly when the patient has undergone or will undergo radiotherapy. It consists of **two parallel horizontal incisions**: one in the upper neck (submandibular) and one in the lower neck (supraclavicular). * **Why it is correct:** The primary advantage of the MacFee incision is its superior vascularity. Unlike trifurcate incisions (like the Crile or Schobinger), it avoids a "triple point" junction where skin flaps are prone to necrosis. This makes it the safest option for patients with prior radiation, as it ensures better wound healing and provides excellent cosmetic results. **Analysis of Incorrect Options:** * **A. Kocher Incision:** A subcostal incision used for **Open Cholecystectomy**. (Note: A "Kocher’s collar incision" is used for thyroidectomy, but "Kocher incision" alone refers to the gallbladder approach). * **B. Gridiron Incision:** A muscle-splitting oblique incision in the right iliac fossa used for **Appendectomy** (McBurney’s point). * **D. Sistrunk Incision/Procedure:** This is the definitive surgical management for a **Thyroglossal Cyst**, involving the removal of the cyst, the tract, and the central part of the hyoid bone. **High-Yield Pearls for NEET-PG:** * **Modified Radical Neck Dissection (MRND):** Unlike Radical Neck Dissection (RND), MRND preserves one or more non-lymphatic structures: the Spinal Accessory Nerve (SAN), Internal Jugular Vein (IJV), or Sternocleidomastoid (SCM) muscle. * **Type I MRND:** Preserves SAN. * **Type II MRND:** Preserves SAN and IJV. * **Type III MRND (Functional Neck Dissection):** Preserves all three (SAN, IJV, and SCM). * **Other Neck Incisions:** Hayes Martin and Schobinger are trifurcate incisions used historically but carry a higher risk of flap necrosis at the junction.

Q: Metastasis of carcinoma of the buccal mucosa typically goes to which of the following locations?

Regional lymph nodes. **Explanation:** **1. Why the correct answer is right:** Carcinoma of the buccal mucosa (most commonly **Squamous Cell Carcinoma**) follows a predictable pattern of spread. Like most head and neck epithelial malignancies, it primarily spreads via the **lymphatic system** rather than the bloodstream in its early and intermediate stages. The buccal mucosa has a rich lymphatic network that drains primarily into the **Level I (submandibular and submental)** and **Level II (upper jugular)** cervical lymph nodes. Therefore, regional lymphadenopathy is the most common site of metastasis at the time of presentation. **2. Why the incorrect options are wrong:** * **Head & Brain (Options A & B):** Direct extension to the head (bones/skin) occurs via local invasion, not metastasis. Brain metastasis from oral cavity cancers is extremely rare and usually occurs only in terminal, end-stage disease. * **Lungs (Option D):** While the lungs are the most common site for **distant (hematogenous)** metastasis in head and neck cancers, distant spread occurs much less frequently and much later than regional lymphatic spread. **3. Clinical Pearls for NEET-PG:** * **Most common site of oral cavity cancer in India:** Buccal mucosa (often associated with betel nut/tobacco chewing, known as the "Indian Oral Carcinoma"). * **Staging:** The presence of regional lymph node metastasis is the single most important prognostic factor in oral cavity SCC. * **Drainage Pattern:** Buccal mucosa → Submandibular nodes (Level Ib) → Deep cervical nodes. * **Verrucous Carcinoma (Ackerman’s Tumor):** A variant of buccal cancer that is locally aggressive but characteristically does **not** show lymphatic metastasis.

Question 1

Sistrunk's operation consists of?

Accepted Answer

Excision of central part of hyoid bone and cone of tongue muscle up to foramen cecum

Answer

Excision of hyoid bone and cone of tongue muscle

Answer

Excision of hyoid bone and the cyst

Answer

Excision of cyst only

Question 2

Modified radical neck dissection includes which of the following?

Accepted Answer

Levels I-V

Answer

Levels I-IV

Answer

Levels I-VII

Answer

Levels I-III

Question 3

A potato tumor is a tumor of which of the following structures?

Accepted Answer

Carotid body

Answer

Sternocleidomastoid muscle

Answer

Carotid sinus

Answer

None of the above

Question 4

Which of the following is NOT true for carcinoma of the tongue?

Accepted Answer

Adenocarcinoma is the commonest type

Answer

Lateral border is involved

Answer

Cervical lymph node involvement is common

Answer

Tobacco chewing is a significant risk factor

Question 5

A midline swelling is seen in all except:

Accepted Answer

Branchial cyst

Answer

Thyroglossal cyst

Answer

Submental lymphadenopathy

Answer

Substernal cyst

Question 6

Which of the following can cause complications with treatment of mandibular fracture?

Accepted Answer

Compression plate

Answer

Miniplate

Answer

Intermaxillary fixation (IMF)

Answer

Reconstruction plate

Question 7

What is the principal purpose of an acrylic splint in surgical procedures?

Accepted Answer

To prevent hematoma formation

Answer

To prevent dry socket

Answer

To prevent infection

Answer

All of the above

Question 8

What is true about a ranula?

Accepted Answer

A mucocele in the floor of the mouth due to trauma of the submandibular gland duct is called a ranula.

Answer

A ranula is typically painful.

Answer

A ranula does not move along with the movement of the tongue.

Answer

All of the above.

Question 9

Which incision is used for modified radical neck dissection?

Accepted Answer

Macfee incision

Answer

Kocher incision

Answer

Grid iron incision

Answer

Sistrunk incision

Question 10

Metastasis of carcinoma of the buccal mucosa typically goes to which of the following locations?

Accepted Answer

Regional lymph nodes

Answer

Head

Answer

Brain

Answer

Lungs

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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