Head and Neck Surgery Practice Questions

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

Auriculotemporal nerve. 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.

Q: A patient with oral cancer involving the mandible is managed by which of the following treatment modalities?

Resection followed by radiotherapy. **Explanation:** The management of oral cancer depends on the stage and the involvement of adjacent structures. When oral cancer involves the **mandible**, it is classified as T4a disease (locally advanced). **1. Why Option C is Correct:** The standard of care for locally advanced oral squamous cell carcinoma (OSCC) with bone involvement is **upfront surgical resection** (composite resection/commando operation) with adequate margins. Bone involvement is a poor prognostic factor and a high-risk feature. Therefore, surgery is followed by **Adjuvant Radiotherapy (RT)** or Chemoradiotherapy (CRT) to eliminate microscopic residual disease and reduce the risk of local recurrence. **2. Why other options are incorrect:** * **Options A & B:** Chemotherapy or Radiotherapy alone are rarely curative for T4 lesions. Furthermore, radiotherapy is less effective when there is gross bone invasion because the hypoxic environment of the bone limits the efficacy of radiation, and there is a high risk of **osteoradionecrosis** if high doses are used on an involved mandible. * **Option D:** Neoadjuvant radiotherapy (RT before surgery) is generally avoided in the oral cavity as it increases surgical complications, impairs wound healing (especially for flaps), and delays definitive surgical clearance. **Clinical Pearls for NEET-PG:** * **Mandibular Involvement:** If the tumor is close to the bone but not invading the cortex, a **marginal mandibulectomy** is done. If the marrow is involved, a **segmental mandibulectomy** is required. * **Indications for Adjuvant RT:** T3/T4 stage, positive/close margins, perineural invasion (PNI), or lymphovascular invasion (LVI). * **Indications for Adjuvant CRT:** The "Gold Standard" for adding chemotherapy to radiation post-surgery is the presence of **Extracapsular Spread (ECS)** in lymph nodes or **positive surgical margins**.

Q: In which of the following head and neck cancers is lymph node metastasis least common?

Hard palate. **Explanation:** The frequency of cervical lymph node metastasis in oral cavity cancers is primarily determined by the density of the lymphatic network and the muscularity of the site. **Why Hard Palate is Correct:** The **hard palate** and the **upper maxillary alveolus** have a sparse lymphatic network and are composed of mucoperiosteum tightly bound to bone. Due to this anatomical lack of deep muscle involvement and low lymphatic density, the incidence of clinically positive nodes at presentation is the lowest among oral cavity sites (approx. 10–15%). **Analysis of Incorrect Options:** * **Tongue (Option A):** The tongue is highly muscular and has a rich, decussating lymphatic plexus. It has the **highest rate** of early lymphatic spread (often bilateral), with up to 40–50% of patients presenting with nodal disease. * **Buccal Mucosa (Option B):** This site is rich in lymphatics that drain into the submandibular (Level II) and facial nodes. It has a significantly higher metastatic potential than the hard palate. * **Lower Alveolus (Option D):** While the gingiva itself has modest lymphatics, tumors here frequently invade the underlying floor of the mouth or the mylohyoid muscle, leading to early involvement of Level I and II nodes. **Clinical Pearls for NEET-PG:** * **Most common site of Oral Cancer:** Lower lip (Global); Tongue/Buccal Mucosa (India). * **Highest risk of Nodal Metastasis:** Tongue and Floor of Mouth. * **Lowest risk of Nodal Metastasis:** Hard palate and Upper Alveolus. * **Nodal Levels:** Oral cavity cancers typically drain first to **Level I (Submental/Submandibular)** and **Level II (Upper Jugular)** nodes. * **Skip Metastasis:** Characteristically seen in Tongue cancers (nodes in Level III or IV involved without Level I or II).

Q: In the Lingual split technique, which instrument is used to cut the tooth?

Chisel. The **Lingual Split Technique** (originally described by Sir William Kelsey Fry) is a classic surgical method used for the removal of impacted mandibular third molars. ### **Why Chisel is the Correct Answer** The fundamental principle of the Lingual Split Technique is to remove the thin plate of bone on the lingual aspect of the mandible to facilitate tooth delivery. A **chisel** is specifically used because it is designed to cut and split bone or teeth along natural grain lines. In this technique, a sharp chisel and mallet are used to perform a "disto-lingual" bone cut, which allows the lingual plate to be fractured or "split" away, providing a clear path for the tooth. ### **Analysis of Incorrect Options** * **B. Osteotome:** Unlike a chisel (which is beveled on one side for cutting), an osteotome is beveled on both sides and is primarily used for compressing or widening bone rather than splitting it cleanly. * **C. Straight Elevator:** This is a luxating instrument used to disrupt the periodontal ligament and lift the tooth from its socket, not for cutting the tooth or bone. * **D. Surgical Bur:** While burs are used in the "Bur Technique" (modern surgical extraction) to remove bone and section teeth, the Lingual Split Technique is defined by its use of hand instruments (chisel and mallet) to avoid the heat generation and potential emphysema associated with high-speed drills. ### **High-Yield Clinical Pearls for NEET-PG** * **Indication:** Most commonly used for disto-angular or vertically impacted mandibular third molars in young patients where the bone is elastic. * **Advantage:** Faster than the bur technique and avoids thermal damage to the bone. * **Complication:** The most significant risk associated with this technique is **Lingual Nerve injury** due to the proximity of the nerve to the lingual plate. * **Key Instrument:** Always associate "Lingual Split" with the **Chisel and Mallet**.

Q: A cyst around the crown of an unerupted tooth is most commonly which of the following?

Dentigerous cyst. **Explanation:** The correct answer is **Dentigerous cyst** (also known as a Follicular cyst). **1. Why Dentigerous Cyst is Correct:** A dentigerous cyst is an odontogenic cyst that originates from the separation of the follicle from around the crown of an **unerupted tooth**. It is the most common developmental odontogenic cyst. Pathologically, it attaches to the **cemento-enamel junction (CEJ)**, enclosing the crown within the cystic space. It most frequently involves the mandibular third molars, followed by maxillary canines. **2. Why the Other Options are Incorrect:** * **Periapical and Radicular Cyst (Options A & B):** These terms are often used interchangeably. They are inflammatory cysts found at the **apex (root)** of a non-vital, erupted tooth, usually due to dental caries or pulpitis. They do not surround the crown of an unerupted tooth. * **Odontogenous Cyst (Option D):** This is a broad category (a "family" of cysts) that includes dentigerous, radicular, and keratocysts. While a dentigerous cyst is a type of odontogenic cyst, it is not the most specific or correct answer for a cyst specifically surrounding an unerupted crown. **3. NEET-PG Clinical Pearls:** * **Radiological Appearance:** Typically presents as a well-defined, unilocular radiolucency associated with the crown of an impacted tooth. * **Most Common Site:** Mandibular 3rd molar. * **Potential Complication:** If left untreated, it can lead to the development of an Ameloblastoma or Squamous Cell Carcinoma (though rare). * **Treatment:** Enucleation and extraction of the involved tooth. * **Differential Diagnosis:** Odontogenic Keratocyst (OKC) and Unicystic Ameloblastoma.

Q: A 45-year-old chronic tobacco chewer presents with a 1.5 cm oral cavity mass and a single ipsilateral neck lymph node. What is the TNM stage of the tumor?

T1N1. **Explanation:** The staging of oral cavity squamous cell carcinoma follows the **AJCC 8th Edition TNM classification**. To determine the stage, we must analyze the primary tumor (T) and the regional lymph nodes (N) separately. 1. **T-Stage (Primary Tumor):** * **T1:** Tumor size ≤ 2 cm and Depth of Invasion (DOI) ≤ 5 mm. * **T2:** Tumor size ≤ 2 cm with DOI > 5 mm OR tumor size 2–4 cm with DOI ≤ 10 mm. * In this case, the mass is **1.5 cm**, which falls under the **T1** category (assuming standard depth for a small lesion). 2. **N-Stage (Regional Lymph Nodes):** * **N1:** Metastasis in a **single ipsilateral** lymph node, **≤ 3 cm** in greatest dimension, and ENE (extranodal extension) negative. * The patient has a single ipsilateral node, making it **N1**. **Why the other options are incorrect:** * **T1N3:** N3 represents a node > 6 cm or any node with clinical extranodal extension. This is too advanced for a single node. * **T3N1:** T3 requires a tumor > 4 cm or DOI > 10 mm. A 1.5 cm mass does not meet this criteria. * **T2N2:** T2 requires a larger tumor size (2-4 cm). N2 involves multiple nodes, bilateral nodes, or a single node between 3–6 cm. **High-Yield Clinical Pearls for NEET-PG:** * **AJCC 8th Edition Update:** The most significant change in oral cavity staging is the inclusion of **Depth of Invasion (DOI)**, not just surface diameter. * **Most Common Site:** The lower lip is the most common site for oral cancer globally, but in India, the **buccal mucosa** (due to tobacco chewing) is most frequent. * **Nodal Level:** Oral cavity cancers typically spread first to **Level I, II, and III** neck nodes. * **Management:** T1N1 lesions are generally treated with wide local excision of the primary tumor and a neck dissection (usually Selective Neck Dissection).

Question 1

Which among the following is the most common neoplasm of the salivary gland?

Accepted Answer

Pleomorphic adenoma

Answer

Adenoid cystic carcinoma

Answer

Mucoepidermoid carcinoma

Answer

Mixed tumor

Question 2

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

Accepted Answer

Auriculotemporal nerve

Answer

Lingual nerve

Answer

Marginal mandibular nerve

Answer

Hypoglossal nerve

Question 3

A patient with oral cancer involving the mandible is managed by which of the following treatment modalities?

Accepted Answer

Resection followed by radiotherapy

Answer

Chemotherapy alone

Answer

Radiotherapy alone

Answer

Radiotherapy followed by resection

Question 4

In which condition does the jaw deviate to the same side?

Accepted Answer

All of the above

Answer

TMJ ankylosis

Answer

Hypoplasia of condyle

Answer

Subcondylar fractures

Question 5

In which of the following head and neck cancers is lymph node metastasis least common?

Accepted Answer

Hard palate

Answer

Tongue

Answer

Buccal mucosa

Answer

Lower alveolus

Question 6

Which of the following is true about thyroglossal cyst?

Accepted Answer

Resolves spontaneously in 20-30% cases.

Answer

Secondary infection leads to sinus.

Answer

40% contains heterotopic thyroid tissue.

Answer

The thyroglossal duct obliterates by the 18th week of intra-uterine life.

Question 7

In the Lingual split technique, which instrument is used to cut the tooth?

Accepted Answer

Chisel

Answer

Osteotome

Answer

Straight elevator

Answer

Surgical bur

Question 8

A cyst around the crown of an unerupted tooth is most commonly which of the following?

Accepted Answer

Dentigerous cyst

Answer

Periapical cyst

Answer

Radicular cyst

Answer

Odontogenous cyst

Question 9

A 45-year-old chronic tobacco chewer presents with a 1.5 cm oral cavity mass and a single ipsilateral neck lymph node. What is the TNM stage of the tumor?

Accepted Answer

T1N1

Answer

T1N3

Answer

T3N1

Answer

T2N2

Question 10

All of the following are true regarding cystic hygroma EXCEPT?

Accepted Answer

Sclerotherapy may be beneficial

Answer

May be present at birth

Answer

Brilliantly transilluminant

Answer

Increases in size on coughing

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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