Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 231: Opsoclonus-myoclonus syndrome is encountered as a clinical feature of which of the following conditions?

A. Meningioma
B. Cerebral atrophy (Correct Answer)
C. Excision
D. Neurofibromatosis

Explanation: **Explanation:** **Opsoclonus-myoclonus syndrome (OMS)**, often referred to as "dancing eyes-dancing feet" syndrome, is a rare neurological disorder characterized by chaotic, multi-directional eye movements (opsoclonus) and involuntary muscle jerks (myoclonus). **Why Cerebral Atrophy is the Correct Answer:** In the context of this specific question, **cerebral atrophy** (specifically cerebellar or brainstem atrophy) is the structural consequence often seen in chronic or progressive cases of OMS. While OMS is frequently paraneoplastic or post-viral, the underlying pathophysiology involves autoimmune-mediated damage to the cerebellum (specifically the fastigial nucleus) and the brainstem. Over time, this neuro-inflammation can lead to visible **cerebral and cerebellar atrophy** on neuroimaging. **Analysis of Incorrect Options:** * **Meningioma:** This is a benign tumor of the arachnoid cap cells. While it can cause focal neurological deficits or seizures depending on its location, it is not classically associated with the diffuse, rhythmic movements of OMS. * **Excision:** This is a surgical procedure, not a pathological condition. While surgical excision of a neuroblastoma (the most common cause of OMS in children) is part of treatment, "excision" itself does not cause the syndrome. * **Neurofibromatosis (NF):** NF-1 and NF-2 are genetic disorders characterized by nerve sheath tumors (neurofibromas/schwannomas) and Lisch nodules. They do not typically present with opsoclonus-myoclonus. **High-Yield Clinical Pearls for NEET-PG:** * **The "Rule of 50%":** In children, approximately 50% of OMS cases are associated with an underlying **Neuroblastoma**. * **Adult Etiology:** In adults, OMS is most commonly a paraneoplastic manifestation of **Small Cell Lung Cancer (SCLC)** or breast cancer. * **Biomarker:** Look for **Anti-Ri (ANNA-2)** antibodies in adult paraneoplastic cases. * **Anatomical Site:** The primary pathology is localized to the **cerebellum** (disruption of the inhibitory control of saccades).

Question 232: What is true about a ranula?

A. A mucocele in the floor of the mouth due to trauma of the submandibular gland duct is called a ranula. (Correct Answer)
B. A ranula is typically painful.
C. A ranula does not move along with the movement of the tongue.
D. All of the above.

Explanation: A **ranula** is a clinical term for a mucous extravasation cyst (mucocele) occurring specifically in the floor of the mouth. ### **Explanation of Options** * **Option A (Correct):** A ranula typically arises from the **sublingual gland** (most common) or the **submandibular gland duct**. It occurs when trauma or obstruction leads to the rupture of a duct, causing mucus to leak into the surrounding tissues of the sublingual space. The name "ranula" is derived from the Latin word *rana* (frog), as the bluish, translucent swelling resembles a frog's belly. * **Option B (Incorrect):** Ranulas are characteristically **painless**, slow-growing, and fluctuant. Pain only occurs if the cyst becomes secondarily infected. * **Option C (Incorrect):** Because a ranula is located in the floor of the mouth, it is often displaced or compressed during tongue protrusion or swallowing. It does not have a midline attachment like a thyroglossal cyst, but its position causes it to **move or be affected by tongue movements**. ### **High-Yield Clinical Pearls for NEET-PG** * **Plunging Ranula:** This occurs when the mucus extravasates through or around the **mylohyoid muscle** into the submandibular space, presenting as a neck swelling. * **Clinical Sign:** It is a **transilluminant** swelling (brilliantly translucent) located lateral to the midline. * **Treatment:** The gold standard treatment is **marsupialization** or, more definitively, **excision of the cyst along with the offending sublingual gland** to prevent recurrence. Simple aspiration has a very high recurrence rate. * **Differential Diagnosis:** Must be distinguished from a dermoid cyst (which is usually midline and has a "doughy" feel).

Question 233: Which incision is used for modified radical neck dissection?

A. Kocher incision
B. Grid iron incision
C. Macfee incision (Correct Answer)
D. Sistrunk incision

Explanation: **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.

Question 234: Which of the following is never a cause of thyroglossal fistula?

A. Infection of a thyroglossal cyst
B. Inadequate removal of a thyroglossal cyst
C. Congenital anomaly (Correct Answer)
D. None of the above

Explanation: ### Explanation The correct answer is **C. Congenital anomaly**. #### 1. Why "Congenital anomaly" is the correct answer A **thyroglossal fistula** is never congenital; it is always **acquired**. During embryonic development, the thyroid gland descends from the foramen caecum to its adult position, leaving behind the thyroglossal duct. If this duct fails to obliterate, it forms a **thyroglossal cyst**. Because the duct is a "blind track" (it does not naturally open onto the skin surface), a fistula can only form if the cyst’s integrity is breached. Therefore, a child is never born with a thyroglossal fistula. #### 2. Why the other options are incorrect * **Infection of a thyroglossal cyst (Option A):** This is a common cause. An infected cyst can form an abscess that ruptures spontaneously through the skin, creating a fistulous communication. * **Inadequate removal (Option B):** This is the most common cause of a recurrent fistula. If the central portion of the hyoid bone is not removed (Sistrunk procedure) or if a portion of the tract is left behind, a persistent draining sinus/fistula develops post-operatively. * **None of the above (Option D):** This is incorrect because "Congenital anomaly" is a scientifically established exclusion. #### 3. NEET-PG Clinical Pearls * **Clinical Presentation:** A thyroglossal cyst/fistula is typically located in the midline and **moves upward on protrusion of the tongue** (due to its attachment to the hyoid bone and foramen caecum). * **Surgical Management:** The gold standard treatment is the **Sistrunk Operation**. This involves excision of the cyst, the entire tract, and the **central 1/3rd of the hyoid bone** to minimize recurrence. * **Lining:** The cyst is usually lined by pseudostratified ciliated columnar epithelium. * **Carcinoma:** If malignancy occurs within a thyroglossal cyst (rare, <1%), the most common type is **Papillary Carcinoma of the Thyroid**.

Question 235: Metastasis of carcinoma of the buccal mucosa typically goes to which of the following locations?

A. Head
B. Brain
C. Regional lymph nodes (Correct Answer)
D. Lungs

Explanation: **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 236: Which among the following is the most common neoplasm of the salivary gland?

A. Pleomorphic adenoma (Correct Answer)
B. Adenoid cystic carcinoma
C. Mucoepidermoid carcinoma
D. Mixed tumor

Explanation: **Explanation:** The correct answer is **Pleomorphic adenoma**. **1. Why Pleomorphic Adenoma is correct:** Pleomorphic adenoma, also known as a **Benign Mixed Tumor**, is the most common neoplasm of the salivary glands overall. It accounts for approximately 60-70% of all parotid tumors and about 50% of all salivary gland tumors. It is characterized by its "pleomorphic" nature, containing both epithelial and mesenchymal (mucoid, myxoid, or chondroid) components. It typically presents as a slow-growing, painless, firm swelling, most commonly in the superficial lobe of the parotid gland. **2. Why other options are incorrect:** * **Adenoid Cystic Carcinoma:** While it is the most common malignant tumor of the **submandibular and minor salivary glands**, it is not the most common salivary neoplasm overall. It is known for its "Swiss cheese" appearance on histology and a high propensity for perineural invasion. * **Mucoepidermoid Carcinoma:** This is the **most common malignant** salivary gland tumor in both adults and children. However, benign tumors (like Pleomorphic Adenoma) are far more frequent than malignant ones. * **Mixed Tumor:** While Pleomorphic Adenoma is a "mixed tumor," the term "Mixed tumor" in Option D is less specific than the formal clinical name "Pleomorphic adenoma." In medical exams, always choose the most specific histological name provided. **Clinical Pearls for NEET-PG:** * **Rule of 80s (Parotid):** 80% of salivary tumors are in the Parotid; 80% of Parotid tumors are Pleomorphic Adenomas; 80% are in the superficial lobe. * **Malignancy Risk:** The smaller the gland, the higher the chance of malignancy (Parotid < Submandibular < Sublingual/Minor glands). * **Warthin’s Tumor:** The second most common benign parotid tumor; it is often bilateral and strongly associated with smoking. * **Treatment:** For Pleomorphic Adenoma, the treatment of choice is **Superficial Parotidectomy** to avoid recurrence and injury to the Facial Nerve.

Question 237: All of the following nerves are at risk during submandibular gland excision except?

A. Lingual nerve
B. Marginal mandibular nerve
C. Auriculotemporal nerve (Correct Answer)
D. Hypoglossal nerve

Explanation: The submandibular gland is located in the submandibular triangle, and its surgical excision requires careful dissection to avoid injuring three major nerves that lie in close proximity. ### **Why Auriculotemporal Nerve is the Correct Answer** The **Auriculotemporal nerve** is a branch of the mandibular nerve (V3) that travels upwards, passing through the parotid gland to provide sensory innervation to the auricle and temple. It also carries postganglionic parasympathetic fibers to the **parotid gland**. Because of its superior and posterior anatomical location, it is at risk during **parotidectomy**, not submandibular gland excision. ### **Analysis of Other Options (Nerves at Risk)** * **Marginal Mandibular Nerve:** This branch of the Facial nerve (CN VII) runs superficial to the submandibular gland, just deep to the platysma. It is the most commonly injured nerve during this surgery, leading to drooping of the corner of the mouth. * **Lingual Nerve:** Located deep to the gland in the floor of the mouth, it loops under the submandibular duct (Wharton’s duct). It is at risk during the ligation of the duct. * **Hypoglossal Nerve (CN XII):** This nerve lies deep to the tendon of the digastric muscle and the submandibular gland. Injury results in ipsilateral tongue deviation. ### **NEET-PG High-Yield Pearls** * **Hayes Martin Maneuver:** To protect the marginal mandibular nerve, the incision is made 2 cm below the lower border of the mandible, and the deep cervical fascia is incised to retract the nerve superiorly within the flap. * **Ganglion Connection:** The submandibular ganglion (parasympathetic) "hangs" from the lingual nerve and must be divided to release the gland. * **Frey’s Syndrome:** This condition involves gustatory sweating due to injury to the **auriculotemporal nerve** during parotid surgery, further distinguishing it from submandibular procedures.

Question 238: Which of the following structures does not move with deglutition?

A. Thyroglossal cyst
B. Thyroid nodule
C. Sublingual dermoid (Correct Answer)
D. Paratracheal nodes

Explanation: The movement of neck swellings during deglutition (swallowing) is a classic clinical sign used to differentiate midline and lateral neck masses. ### **Why Sublingual Dermoid is the Correct Answer** A **sublingual dermoid** is a developmental cyst located in the floor of the mouth (either above or below the mylohyoid muscle). Unlike thyroid-related structures, it has **no anatomical attachment** to the larynx, trachea, or the hyoid bone. Therefore, it remains stationary during swallowing. ### **Analysis of Incorrect Options** * **Thyroid Nodule:** The thyroid gland is enclosed within the **pretracheal fascia**, which is attached to the cricoid and thyroid cartilages. As the larynx moves upward during deglutition, the thyroid gland and any nodules within it move with it. * **Thyroglossal Cyst:** These cysts are remnants of the thyroglossal duct, which is intimately associated with the **hyoid bone**. Because the hyoid bone moves upward during swallowing, the cyst moves as well. (Note: It also moves with **protrusion of the tongue** due to its attachment to the foramen caecum). * **Paratracheal Nodes:** These are closely related to the trachea and are often tucked under the thyroid gland or pretracheal fascia. When enlarged (e.g., due to malignancy or infection), they frequently move with the trachea during deglutition. ### **NEET-PG High-Yield Pearls** * **Movement with Deglutition:** Thyroid swellings, Thyroglossal cysts, Subhyoid bursitis, and Laryngocele. * **Movement with Tongue Protrusion:** Only **Thyroglossal cysts** (pathognomonic sign). * **Exceptions:** A thyroid swelling may **fail to move** with deglutition if it is fixed by advanced malignancy (Anaplastic CA) or Riedel’s thyroiditis. * **Sublingual Dermoid vs. Ranula:** A dermoid is midline and opaque/doughy, whereas a ranula is usually lateral to the midline and translucent (plunging ranulas can appear in the neck).

Question 239: Which of the following is true about thyroglossal cyst?

A. Secondary infection leads to sinus.
B. 40% contains heterotopic thyroid tissue.
C. Resolves spontaneously in 20-30% cases. (Correct Answer)
D. The thyroglossal duct obliterates by the 18th week of intra-uterine life.

Explanation: ### Explanation: Thyroglossal Cyst A thyroglossal cyst is the most common congenital neck swelling, arising from the persistent remnants of the thyroglossal duct during the descent of the thyroid gland from the foramen caecum to its adult position. **1. Why Option C is Correct:** While most thyroglossal cysts require surgical intervention (Sistrunk procedure) due to the risk of infection or rare malignancy, clinical studies and longitudinal observations indicate that approximately **20-30% of small, asymptomatic cysts may undergo spontaneous resolution** or remain dormant without clinical progression throughout life. **2. Analysis of Incorrect Options:** * **Option A:** A thyroglossal **fistula** is almost always acquired, not congenital. It typically follows the rupture of an infected cyst or incomplete surgical excision. While infection leads to a fistula, the term "sinus" (a blind-ending track) is technically less accurate in this clinical progression than "fistula" (communication between the skin and the foramen caecum). * **Option B:** Heterotopic thyroid tissue is found in approximately **1-2%** of cases, not 40%. However, it is vital to ensure the cyst isn't the patient's *only* functioning thyroid tissue via ultrasound before excision. * **Option D:** The thyroglossal duct normally obliterates by the **8th to 10th week** of intrauterine life. Persistence beyond this period leads to cyst formation. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** A midline neck swelling that **moves upward on protrusion of the tongue** (due to its attachment to the hyoid bone/foramen caecum). * **Location:** Most common site is **subhyoid** (50%). * **Surgery of Choice:** **Sistrunk Operation**, which involves excision of the cyst, the entire duct track, and the **central part of the hyoid bone** to prevent recurrence. * **Malignancy:** Rare (<1%), most commonly **Papillary Carcinoma of the Thyroid**.

Question 240: The internal orifice of a branchial fistula is typically located at which of the following anatomical sites?

A. Lower third of the neck over the anterior border of the sternocleidomastoid muscle
B. Floor of the external auditory canal
C. Posterior tonsillar pillar (Correct Answer)
D. Anterior to the tragus on the ipsilateral side

Explanation: **Explanation:** The question refers to a **Second Branchial Cleft Fistula**, which is the most common type of branchial anomaly (95%). These anomalies result from the failure of the second branchial cleft and cervical sinus of His to obliterate. **1. Why the Correct Answer is Right:** The tract of a second branchial cleft fistula follows a specific embryological path: it starts at an external opening in the lower neck, ascends along the carotid sheath, passes **between the internal and external carotid arteries**, and travels superficial to the glossopharyngeal and hypoglossal nerves. It ultimately opens internally into the **tonsillar fossa**, specifically on the **posterior tonsillar pillar** or the supratonsillar fossa. **2. Analysis of Incorrect Options:** * **Option A:** This describes the typical **external orifice** of a second branchial fistula, not the internal one. * **Option B:** The floor of the external auditory canal is the internal opening site for **First Branchial Cleft anomalies** (Work Type I and II). * **Option D:** This location is characteristic of **Preauricular sinuses**, which are distinct from branchial fistulae and relate to the fusion of the auricular hillocks of His. **3. Clinical Pearls for NEET-PG:** * **First Branchial Cleft:** Internal opening is in the External Auditory Canal; closely related to the **Facial Nerve**. * **Second Branchial Cleft:** Most common; passes between the **Carotids**; internal opening in the **Tonsillar Fossa**. * **Third Branchial Cleft:** Internal opening in the **Piriform Fossa**; passes posterior to the internal carotid artery and pierces the thyrohyoid membrane. * **Fourth Branchial Cleft:** Extremely rare; internal opening at the **apex of the Piriform Fossa**; associated with recurrent thyroid abscesses.

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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