Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 221: Sistrunk's operation consists of?

A. Excision of hyoid bone and cone of tongue muscle
B. Excision of hyoid bone and the cyst
C. Excision of central part of hyoid bone and cone of tongue muscle up to foramen cecum (Correct Answer)
D. Excision of cyst only

Explanation: ### Explanation **Sistrunk’s operation** is the definitive surgical treatment for a **thyroglossal duct cyst**. The procedure is based on the embryological development of the thyroid gland, which descends from the **foramen cecum** at the base of the tongue to its final position in the neck. During this descent, the duct passes in close proximity to (and often through) the **hyoid bone**. **Why Option C is correct:** The hallmark of Sistrunk’s operation is the removal of the entire tract to prevent recurrence. This involves: 1. Excision of the cyst. 2. **Excision of the central part (body) of the hyoid bone**, as the duct is intimately related to it. 3. Excision of a **core/cone of muscle** (genioglossus and geniohyoid) along with the tract up to the **foramen cecum**. **Why other options are incorrect:** * **Option A & B:** These are incomplete descriptions. Removing only the hyoid or the cyst without tracing the tract to the foramen cecum leads to a high recurrence rate (approx. 30-50%). * **Option D:** Simple cyst excision (Schlange’s operation) is obsolete due to the extremely high risk of recurrence. --- ### NEET-PG High-Yield Pearls * **Recurrence Rate:** With Sistrunk’s operation, the recurrence rate drops to **<3%**, compared to ~50% with simple excision. * **Most Common Location:** The most common site for a thyroglossal cyst is **subhyoid** (infrahyoid). * **Clinical Sign:** A thyroglossal cyst is a midline swelling that **moves upward on protrusion of the tongue** (due to its attachment to the foramen cecum) and on deglutition. * **Ectopic Thyroid:** Always perform an ultrasound/thyroid scan before surgery to ensure the cyst is not the patient’s **only functioning thyroid tissue**. * **Malignancy:** The most common malignancy found in a thyroglossal cyst is **Papillary Carcinoma of the Thyroid**.

Question 222: Modified radical neck dissection includes which of the following?

A. Levels I-IV
B. Levels I-VII
C. Levels I-III
D. Levels I-V (Correct Answer)

Explanation: ### 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.**

Question 223: In performing a tracheostomy, what is the generally accepted practice?

A. The strap muscles should be divided.
B. The thyroid isthmus should be preserved.
C. The trachea should be entered at the second or third cartilaginous ring. (Correct Answer)
D. Only horizontal incisions should be used.

Explanation: **Explanation:** The primary objective of a tracheostomy is to create a safe airway while minimizing long-term complications. The **second and third tracheal rings** are the ideal site for entry because this location is sufficiently below the cricoid cartilage to prevent subglottic stenosis, yet high enough to avoid injury to the innominate artery or causing a tracheoesophageal fistula. **Analysis of Options:** * **Option C (Correct):** Entering at the 2nd or 3rd ring (sometimes the 4th) is the standard. A "high tracheostomy" (above the 2nd ring) risks damaging the cricoid cartilage, leading to perichondritis and permanent laryngeal stenosis. * **Option A:** The strap muscles (sternohyoid and sternothyroid) are typically **retracted laterally** in the midline raphe rather than divided. This preserves muscle function and reduces bleeding. * **Option B:** While the thyroid isthmus can be retracted upwards or downwards, it is frequently **divided and suture-ligated** to provide better exposure to the tracheal rings and prevent postoperative hemorrhage from the gland. * **Option D:** While the skin incision can be horizontal (for better cosmesis) or vertical (for speed/emergency), the tracheal incision itself can be vertical, cruciate, or a Bjork flap. There is no rule that "only" horizontal incisions are used. **High-Yield Clinical Pearls for NEET-PG:** * **Emergency Airway:** In an acute "cannot intubate, cannot ventilate" scenario, **Cricothyroidotomy** is the procedure of choice, not tracheostomy. * **Most Common Complication:** Immediate – Hemorrhage; Late – Tracheal stenosis. * **Bjork Flap:** An inferiorly based flap of the 2nd/3rd tracheal ring sutured to the skin to create a formal stoma and facilitate easier tube re-insertion.

Question 224: A potato tumor is a tumor of which of the following structures?

A. Carotid body (Correct Answer)
B. Sternocleidomastoid muscle
C. Carotid sinus
D. None of the above

Explanation: **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.

Question 225: Thyroglossal cyst moves with protrusion of the tongue because of its attachment to:

A. Foramen caecum (Correct Answer)
B. Thyroid cartilage
C. Pharyngeal wall
D. Tonsils

Explanation: ### Explanation **1. Why Foramen Caecum is Correct:** The thyroid gland develops from an endodermal diverticulum at the base of the tongue, specifically at the **foramen caecum**. During development, it descends to its adult position in the neck via the **thyroglossal duct**. A thyroglossal cyst is a remnant of this duct. Because the duct remains anatomically connected to the foramen caecum at the base of the tongue, any movement of the tongue (protrusion) pulls on the duct and its associated cyst, causing it to move upward. This is a pathognomonic clinical sign. **2. Why Other Options are Incorrect:** * **B. Thyroid cartilage:** While the cyst is often located near the thyroid cartilage (infrahyoid or suprahyoid), it is not embryologically attached to it. Movement with deglutition (swallowing) occurs because the cyst is attached to the hyoid bone, which moves with the larynx, but tongue protrusion specifically involves the foramen caecum. * **C. Pharyngeal wall:** The thyroglossal duct originates from the floor of the pharynx (tongue base), not the lateral or posterior pharyngeal walls. * **D. Tonsils:** The tonsils develop from the second pharyngeal pouch, which is unrelated to the midline descent of the thyroid gland. **3. Clinical Pearls for NEET-PG:** * **Location:** Most common site is **infrahyoid** (65%), followed by suprahyoid. It is always a **midline** swelling. * **Sistrunk Operation:** The definitive surgical treatment. It involves excision of the cyst, the entire duct tract, and the **central body of the hyoid bone** to prevent recurrence. * **Differential Diagnosis:** A midline swelling that moves with deglutition but *not* with tongue protrusion is likely a thyroid swelling or a submental lymph node. * **Ectopic Thyroid:** Always perform an ultrasound to ensure a normal thyroid gland exists before removal, as the cyst may contain the patient's only functioning thyroid tissue.

Question 226: Which surgical step is essential in the management of a thyroglossal cyst?

A. Excision of the central portion of the hyoid bone (Correct Answer)
B. Dissection of the sternothyroid muscle
C. Isthmusectomy with subtotal thyroidectomy
D. Dissection of strap muscles of the neck

Explanation: **Explanation:** The definitive surgical management for a thyroglossal cyst is the **Sistrunk Operation**. The essential step in this procedure is the **excision of the central portion of the hyoid bone** along with the cyst and its tract. **Why Option A is Correct:** The thyroglossal duct develops from the *foramen caecum* at the base of the tongue and descends to the thyroid's final position. During development, the duct becomes intimately associated with the hyoid bone, often passing through it or wrapping tightly around it. Simple excision of the cyst alone leads to a high recurrence rate (approx. 50%). Removing the central 1–2 cm of the hyoid bone, along with a core of muscle up to the foramen caecum, ensures the entire epithelial tract is removed, reducing recurrence to <3%. **Why Other Options are Incorrect:** * **Option B & D:** While strap muscles (sternohyoid, sternothyroid) are retracted or divided to gain access to the cyst, their dissection is a surgical approach step, not the "essential" curative step of the procedure. * **Option C:** Isthmusectomy is not routinely required unless the cyst is located within the isthmus itself. Subtotal thyroidectomy is irrelevant as the pathology is a developmental duct remnant, not a primary thyroid parenchymal disease. **NEET-PG High-Yield Pearls:** * **Most common location:** Subhyoid (infrahyoid). * **Clinical Sign:** The cyst moves upward on **protrusion of the tongue** (due to its attachment to the foramen caecum) and on deglutition. * **Pre-op Essential:** Always perform an **Ultrasound** to confirm the presence of a normal thyroid gland; the cyst might contain the patient's only functioning thyroid tissue (Ectopic Thyroid). * **Carcinoma:** If malignancy occurs within a thyroglossal cyst, it is most commonly **Papillary Carcinoma**.

Question 227: What is the best treatment for cervical lymph node involvement in papillary carcinoma of the thyroid?

A. Chemotherapy
B. Radioactive iodine
C. Radical neck dissection (Correct Answer)
D. Steroids

Explanation: **Explanation:** In Papillary Carcinoma of the Thyroid (PTC), the primary mode of lymphatic spread is to the cervical lymph nodes. When these nodes are clinically or radiologically involved, the standard of care is surgical clearance. **1. Why Radical Neck Dissection is Correct:** PTC is a **lymphophilic tumor**. While it has an excellent prognosis, nodal metastasis is common. The treatment of choice for confirmed nodal involvement is a **Functional or Modified Radical Neck Dissection (MRND)**. This involves a systematic compartmental clearance (usually Levels II-V) to ensure complete removal of the disease while preserving non-lymphatic structures like the spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle. Simple "node picking" is discouraged due to high recurrence rates. **2. Why Other Options are Incorrect:** * **Chemotherapy:** PTC is generally **chemo-resistant**. Chemotherapy has no role in the primary management of differentiated thyroid cancer. * **Radioactive Iodine (RAI):** While RAI (I-131) is used post-operatively to ablate residual thyroid tissue or treat distant metastases (like lungs/bone), it is **not a substitute for surgery** in the presence of bulky cervical lymphadenopathy. Surgery must precede RAI to reduce tumor burden. * **Steroids:** These have no therapeutic role in treating thyroid malignancy; they are used only for palliative care or managing specific complications like airway edema. **Clinical Pearls for NEET-PG:** * **Most common site of metastasis:** Central compartment (Level VI) nodes. * **Prognosis:** PTC has an excellent 10-year survival rate (>90%), even with nodal involvement. * **Psammoma bodies:** A classic histological hallmark of PTC. * **Prophylactic Neck Dissection:** Not routinely recommended for PTC; surgery is performed only for clinically/radiologically positive nodes (Therapeutic Neck Dissection).

Question 228: A midline swelling is seen in all except:

A. Branchial cyst (Correct Answer)
B. Thyroglossal cyst
C. Submental lymphadenopathy
D. Substernal cyst

Explanation: **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.

Question 229: A person has been brought to the casualty department following a road traffic accident. They experienced transient loss of consciousness, regained it briefly, and then became unconscious again. What is the most likely diagnosis?

A. Intracerebral hemorrhage
B. Subarachnoid hemorrhage
C. Subdural hemorrhage
D. Extradural hemorrhage (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Extradural Hemorrhage (EDH)** The clinical scenario describes the classic **"Lucid Interval,"** which is the hallmark of an Extradural Hemorrhage. This occurs when a patient experiences an initial loss of consciousness (due to concussion), followed by a period of temporary recovery (the lucid interval), and then a rapid neurological deterioration as the expanding hematoma causes increased intracranial pressure and brain herniation. EDH is most commonly caused by a rupture of the **Middle Meningeal Artery** (a branch of the maxillary artery) following a fracture at the **pterion**, where the skull is thinnest. On a CT scan, it typically appears as a **biconvex (lentiform), hyperdense** lesion that does not cross cranial sutures. **Why the other options are incorrect:** * **Subdural Hemorrhage (SDH):** Usually results from the tearing of **bridging veins**. It presents with a more gradual decline in consciousness and appears as a **crescent-shaped** lesion on CT that *can* cross suture lines. * **Subarachnoid Hemorrhage (SAH):** Classically presents as a sudden, "thunderclap headache" (the worst headache of one's life), often due to a ruptured berry aneurysm rather than trauma. * **Intracerebral Hemorrhage:** Involves bleeding within the brain parenchyma itself, usually associated with chronic hypertension or shearing injuries (Diffuse Axonal Injury), rather than the specific "lucid interval" pattern. **NEET-PG High-Yield Pearls:** * **Source of Bleed:** Middle Meningeal Artery (most common). * **CT Appearance:** Convex/Lens-shaped (EDH) vs. Concave/Crescent-shaped (SDH). * **Surgical Management:** Urgent burr hole or craniotomy for evacuation if the hematoma is >30cm³ or the patient is symptomatic. * **The "Lucid Interval"** is pathognomonic for EDH but is only present in about 20-30% of cases.

Question 230: What is the principal purpose of an acrylic splint in surgical procedures?

A. To prevent hematoma formation (Correct Answer)
B. To prevent dry socket
C. To prevent infection
D. All of the above

Explanation: **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.

Practice by Chapter

Salivary Gland Diseases

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Thyroid Gland Disorders

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Parathyroid Gland Disorders

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Neck Masses Evaluation

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Oral Cavity Lesions

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Laryngeal Disorders

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Head and Neck Cancer

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Reconstructive Techniques in Head and Neck Surgery

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Surgical Management of Sleep Apnea

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Airway Management in Head and Neck Surgery

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Surgical Approaches to the Neck

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Neck Dissection Techniques

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