Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 241: A cyst around the crown of an unerupted tooth is most commonly which of the following?

A. Periapical cyst
B. Radicular cyst
C. Dentigerous cyst (Correct Answer)
D. Odontogenous cyst

Explanation: **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.

Question 242: What is the treatment of choice for Warthin's tumor?

A. Superficial parotidectomy (Correct Answer)
B. Enucleation
C. Radiotherapy
D. Injection of a sclerosant agent

Explanation: **Explanation:** **Warthin’s Tumor (Papillary Cystadenoma Lymphomatosum)** is the second most common benign salivary gland tumor, typically occurring in the tail of the parotid gland. **Why Superficial Parotidectomy is the Correct Answer:** The standard treatment of choice is **superficial parotidectomy** (with preservation of the facial nerve). This approach is preferred because Warthin’s tumors are often multicentric (10-15% of cases) and can be bilateral. Removing the superficial lobe ensures complete excision of the tumor while minimizing the risk of recurrence and protecting the facial nerve branches. **Why Other Options are Incorrect:** * **Enucleation:** This was historically practiced but is now discouraged. Simple enucleation has a high recurrence rate because the tumor capsule is often thin or incomplete, leading to "seeding" of tumor cells. * **Radiotherapy:** Warthin’s tumor is a benign condition. Radiotherapy is reserved for malignant tumors or unresectable aggressive cases; using it here would expose the patient to unnecessary radiation risks (e.g., secondary malignancies). * **Sclerosant Agents:** While some studies explore minimally invasive techniques for elderly, high-risk patients, it is not the standard of choice or a definitive surgical treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Hot Spot on Scan:** Warthin’s tumor is unique because it shows increased uptake on **Technetium-99m pertechnetate scans** (due to the presence of oncocytes). * **Risk Factor:** It is strongly associated with **smoking**. * **Demographics:** Most common in elderly males (though the male-to-female ratio is narrowing). * **Location:** Almost exclusively found in the **parotid gland** (rarely in minor salivary glands). * **Pathology:** Characterized by a double layer of epithelium (oncocytes) and a dense lymphoid stroma with germinal centers.

Question 243: All of the following are true regarding cystic hygroma EXCEPT?

A. May be present at birth
B. Brilliantly transilluminant
C. Increases in size on coughing
D. Sclerotherapy may be beneficial (Correct Answer)

Explanation: **Explanation:** Cystic hygroma is a congenital malformation of the lymphatic system (macrocystic lymphatic malformation) resulting from the failure of the jugular lymph sacs to communicate with the internal jugular vein. **Why Option D is the "Except" (Correct Answer):** The provided answer key is technically controversial in modern practice, but in the context of traditional surgical teaching for NEET-PG, **Sclerotherapy is a standard and beneficial treatment** for macrocystic hygromas. Agents like OK-432 (Picibanil), Bleomycin, or Doxycycline are frequently used to shrink the cyst. If this option is marked as "Except," it implies that either surgery is considered the primary definitive treatment or that the question refers to microcystic variants where sclerotherapy is less effective. However, clinically, sclerotherapy *is* beneficial. **Analysis of Other Options:** * **Option A (Present at birth):** True. About 50-60% are present at birth, and 90% manifest by age two. * **Option B (Brilliantly transilluminant):** True. Because the cysts contain clear, straw-colored lymph fluid and have thin walls, they demonstrate brilliant transillumination, a classic diagnostic sign. * **Option C (Increases in size on coughing):** **False.** This is a characteristic of a **Laryngocele** or a **Plunging Ranula**, not a cystic hygroma. Cystic hygromas do not have a direct communication with the airway or thoracic cavity that would cause a cough impulse. **NEET-PG High-Yield Pearls:** * **Most Common Site:** Posterior triangle of the neck (Left side > Right side). * **Pathology:** Characterized by "sequestration" of lymphatic tissue; histologically shows large spaces lined by a single layer of endothelium. * **Clinical Feature:** It is a soft, painless, compressible, and partially reducible mass. It does not have a cough impulse (unlike Laryngocele). * **Complications:** Sudden increase in size usually indicates hemorrhage into the cyst or secondary infection. * **Association:** Often associated with chromosomal abnormalities like **Turner Syndrome** and Down Syndrome.

Question 244: Which of the following is not a characteristically brilliantly transilluminant swelling?

A. Hydrocele
B. Meningocele
C. Lipoma (Correct Answer)
D. Cystic hygroma

Explanation: **Explanation:** Transillumination is a clinical test where a light source is pressed against a swelling in a dark room. A swelling is **brilliantly transilluminant** if it contains clear, serous fluid and is covered by thin skin. **Why Lipoma is the Correct Answer:** A **Lipoma** is a benign tumor composed of **adipose (fat) tissue**. Because fat is a solid, opaque substance, it does not allow light to pass through. Therefore, lipomas are characteristically **non-transilluminant**. On examination, they are typically soft, lobulated, and exhibit a "slip sign." **Analysis of Incorrect Options:** * **Hydrocele:** This is a collection of clear serous fluid between the layers of the tunica vaginalis in the scrotum. Due to the clear fluid and thin scrotal skin, it is the classic example of a brilliantly transilluminant swelling. * **Meningocele:** This involves the protrusion of meninges containing **Cerebrospinal Fluid (CSF)** through a cranial or spinal defect. Since CSF is a clear liquid, these swellings transilluminate brightly. * **Cystic Hygroma:** A congenital multilocular lymphatic malformation (usually in the posterior triangle of the neck) filled with clear lymph. It is famously known for being brilliantly transilluminant because of its thin-walled lymphatic sacs. **NEET-PG High-Yield Pearls:** * **Brilliantly Transilluminant Swellings:** Hydrocele, Cystic Hygroma, Meningocele, Ranula, and Epididymal cyst. * **The "Slip Sign":** Pathognomonic for Lipoma; the edge of the swelling slips away from the examining finger. * **Cystic Hygroma:** Often presents at birth or by age 2; most common site is the left posterior triangle of the neck. * **Rule of Thumb:** If the fluid is opaque (pus, blood, or solid fat), transillumination will be negative.

Question 245: Which of the following is a component of Pierre Robin Sequence?

A. Glossoptosis (Correct Answer)
B. Airway obstruction
C. Cleft lip
D. Micrognathia

Explanation: **Explanation:** **Pierre Robin Sequence (PRS)** is a clinical triad characterized by a specific developmental chain of events. The term "sequence" is used because one primary defect leads to a cascade of secondary anomalies. 1. **The Correct Answer (A):** **Glossoptosis** (downward/backward displacement of the tongue) is a core component of the triad. In PRS, the primary defect is **Micrognathia** (a small, recessed mandible). This lack of space forces the tongue to fall backward into the oropharynx (Glossoptosis), which subsequently prevents the palatal shelves from fusing, often resulting in a **U-shaped cleft palate**. 2. **Analysis of Incorrect Options:** * **B. Airway obstruction:** While airway obstruction is a critical *clinical consequence* of glossoptosis in PRS, it is considered a symptom/complication rather than a formal component of the anatomical triad. * **C. Cleft lip:** PRS is classically associated with a **Cleft Palate** (specifically U-shaped). Cleft lip is generally *not* a feature of this sequence. * **D. Micrognathia:** This is indeed a component of the triad. However, in many NEET-PG style questions where multiple components are listed, the question may be testing the specific "sequence" or the most definitive anatomical displacement. (Note: If this were a "Multiple Correct" type, both A and D are components; however, in single-best-response formats, Glossoptosis is frequently highlighted as the defining functional defect). **High-Yield Clinical Pearls for NEET-PG:** * **The Triad:** Micrognathia, Glossoptosis, and Cleft Palate. * **Positioning:** Initial management involves **prone or side-lying positioning** to allow gravity to pull the tongue forward and clear the airway. * **Surgical Intervention:** If conservative measures fail, **Mandibular Distraction Osteogenesis (MDO)** or tongue-lip adhesion may be required. * **Associated Syndrome:** Frequently associated with **Stickler Syndrome** (check for ophthalmological and joint issues).

Question 246: What is the most common presentation of an intracranial aneurysm?

A. Coarctation of the aorta
B. Systemic hypertension
C. Hypotension
D. Intracranial hemorrhage (Correct Answer)

Explanation: **Explanation:** **1. Why Intracranial Hemorrhage is Correct:** Intracranial aneurysms, most commonly **Berry (saccular) aneurysms**, are typically asymptomatic until they rupture. When rupture occurs, the most common clinical presentation is **Subarachnoid Hemorrhage (SAH)**. Patients classically describe this as the "worst headache of my life" (thunderclap headache), often accompanied by meningismus, vomiting, and altered consciousness. While some aneurysms may present with mass effect (e.g., 3rd nerve palsy with PCom artery aneurysms), hemorrhage remains the most frequent and significant presentation. **2. Why the Other Options are Incorrect:** * **Coarctation of the Aorta:** This is an **associated condition**, not a presentation. Approximately 5-10% of patients with coarctation have associated Berry aneurysms due to persistent upper-body hypertension. * **Systemic Hypertension:** This is a major **risk factor** for the formation and rupture of an aneurysm, but it is not the "presentation" of the aneurysm itself. * **Hypotension:** This is clinically irrelevant to the presentation of an intracranial aneurysm. In fact, acute rupture often leads to a sympathetic surge, causing transient hypertension. **Clinical Pearls for NEET-PG:** * **Most common site:** Junction of the **Anterior Communicating Artery (A-com)** with the Anterior Cerebral Artery. * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA). * **Initial Investigation of Choice:** Non-contrast CT (NCCT) head to detect blood in the subarachnoid space. * **Associated Conditions:** Autosomal Dominant Polycystic Kidney Disease (ADPKD), Ehlers-Danlos syndrome, and Coarctation of the aorta. * **Complication:** Vasospasm is a major cause of delayed morbidity (treated with **Nimodipine**).

Question 247: In Neuroblastomas, what is the most common presentation?

A. Lytic lesion in the skull with suture diastasis (Correct Answer)
B. Lung metastasis
C. Renal invasion
D. Secondaries in the brain

Explanation: **Explanation:** Neuroblastoma is the most common extracranial solid tumor of childhood, arising from primordial neural crest cells. The correct answer is **A (Lytic lesion in the skull with suture diastasis)** because of the tumor's unique metastatic pattern. 1. **Why Option A is Correct:** Neuroblastoma is notorious for early and widespread hematogenous metastasis, particularly to the bone and bone marrow. When it involves the skull, it typically causes **osteolytic lesions**. As these lesions grow, they increase intracranial pressure and infiltrate the cranial sutures, leading to **suture diastasis** (widening of the sutures). This is a classic radiological finding in pediatric neuroblastoma. 2. **Why the other options are incorrect:** * **Lung metastasis (B):** Unlike Wilms' tumor, lung involvement is rare in neuroblastoma. * **Renal invasion (C):** While neuroblastoma often arises from the adrenal gland (displacing the kidney downward and laterally), it rarely invades the renal parenchyma itself. * **Secondaries in the brain (D):** Metastasis to the brain parenchyma is extremely uncommon; the tumor prefers the skull bones and the retro-orbital space. **Clinical Pearls for NEET-PG:** * **Hutchinson’s Syndrome:** Metastasis to the orbit leading to proptosis and periorbital ecchymosis (**"Raccoon eyes"**). * **Pepper Syndrome:** Massive involvement of the liver by metastatic neuroblastoma. * **Blueberry Muffin Baby:** Cutaneous metastases appearing as bluish-purple nodules. * **Biochemical Marker:** Elevated urinary VMA (Vanillylmandellic acid) and HVA (Homovanillic acid). * **Radiology:** Calcification is seen in 80-90% of cases on CT (unlike Wilms' tumor).

Question 248: Which of the following statements best represents Ludwig's angina?

A. Coronary artery spasm
B. Infection of cellular tissues around the submandibular salivary gland (Correct Answer)
C. Esophageal spasm
D. Retropharyngeal infection

Explanation: **Explanation:** **Ludwig’s Angina** is a rapidly spreading, potentially life-threatening **cellulitis** of the submandibular space. 1. **Why Option B is Correct:** The submandibular space is divided by the mylohyoid muscle into the sublingual and submaxillary spaces. Ludwig’s angina involves **bilateral** infection of these spaces. It is typically polymicrobial (streptococci, staphylococci, and anaerobes) and most commonly originates from an **odontogenic infection** (usually the 2nd or 3rd mandibular molars). The infection is a "brawny" cellulitis rather than an abscess, meaning there is no fluctuance. 2. **Why Other Options are Incorrect:** * **Options A & C:** While the term "Angina" (from the Greek *ankhon*, meaning strangling) is often associated with chest pain (coronary) or swallowing pain (esophageal), in this context, it refers to the sensation of choking and airway obstruction. * **Option D:** Retropharyngeal infection occurs in the space behind the pharynx. While it also causes airway issues, it is a distinct anatomical entity from the submandibular involvement seen in Ludwig’s. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Triad:** Bilateral involvement, gangrenous cellulitis (not abscess), and involvement of both sublingual and submaxillary spaces. * **Key Sign:** "Woody" or brawny edema of the neck and **elevation/protrusion of the tongue**, which leads to airway obstruction. * **Most Common Cause:** Dental infection (80% of cases). * **Management:** The priority is **Airway Management** (often requiring tracheostomy if intubation fails). Treatment includes IV antibiotics and surgical decompression/drainage if conservative management fails.

Question 249: Which of the following is FALSE regarding the management of salivary gland tumors?

A. Fine Needle Aspiration Cytology (FNAC) is the investigation of choice.
B. Chemotherapy is given after surgery. (Correct Answer)
C. Open incisional biopsy is a contraindication.
D. Neck dissection is mandatory for high-grade malignancies.

Explanation: ### Explanation **1. Why Option B is False (The Correct Answer):** In salivary gland tumors, **surgery** is the primary treatment, often followed by **radiotherapy** for high-grade or recurrent cases. Salivary gland malignancies are generally **radioresistant and chemoresistant**. Chemotherapy is not a routine postoperative protocol; it is reserved only for palliative care in advanced, metastatic, or symptomatic recurrent disease where surgery and radiation are no longer options. **2. Analysis of Other Options:** * **Option A (FNAC):** FNAC is indeed the **investigation of choice** for initial evaluation. It has high sensitivity and specificity (approx. 90%) for distinguishing between benign and malignant lesions, helping in surgical planning without the risk of seeding. * **Option C (Open Incisional Biopsy):** This is strictly **contraindicated**, especially in the parotid gland. Breaking the tumor capsule increases the risk of **tumor seeding** (leading to recurrence) and potential damage to the facial nerve. * **Option D (Neck Dissection):** For high-grade malignancies (e.g., Mucoepidermoid carcinoma or Squamous cell carcinoma), the risk of occult nodal metastasis is high. Therefore, a **prophylactic or therapeutic neck dissection** is mandatory to ensure regional oncological control. ### High-Yield Clinical Pearls for NEET-PG: * **Most common tumor:** Pleomorphic Adenoma (Parotid). * **Most common malignancy:** Mucoepidermoid Carcinoma. * **Adenoid Cystic Carcinoma:** Characterized by **perineural invasion** and a "Swiss-cheese" appearance on histology. * **Warthin’s Tumor:** Often bilateral, associated with smoking, and shows "hot spots" on Technetium-99m pertechnetate scan. * **Frey’s Syndrome:** A post-parotidectomy complication diagnosed by the **Minor’s Starch-Iodine test**.

Question 250: All the following statements are true regarding malignant salivary gland tumors EXCEPT?

A. Painful
B. Present with skin ulceration
C. Cervical lymphadenopathy present
D. Simple enucleation is treatment of choice (Correct Answer)

Explanation: **Explanation:** The management of salivary gland tumors depends heavily on their biological behavior. Malignant tumors are characterized by local invasion, rapid growth, and potential for metastasis. **Why Option D is the Correct Answer (The Exception):** Simple enucleation is **never** the treatment of choice for malignant salivary gland tumors. Enucleation (shelling out the tumor) carries a high risk of tumor spillage and incomplete resection, leading to inevitable local recurrence. The standard of care for malignancy is **wide local excision** (e.g., superficial or total parotidectomy) with clear margins, often combined with neck dissection if nodes are involved. Even for benign tumors like Pleomorphic Adenoma, enucleation is avoided to prevent recurrence. **Why the other options are characteristic of Malignancy:** * **Option A (Pain):** While most salivary tumors are painless, the presence of pain often indicates perineural invasion or rapid expansion, which are hallmarks of malignancy (especially Adenoid Cystic Carcinoma). * **Option B (Skin Ulceration):** Malignant tumors are invasive. Ulceration of the overlying skin or fixity to deeper structures indicates advanced local infiltration (T4 disease). * **Option C (Cervical Lymphadenopathy):** Unlike benign tumors, malignant salivary tumors (particularly Mucoepidermoid and Squamous Cell Carcinomas) frequently metastasize to regional cervical lymph nodes. **High-Yield Clinical Pearls for NEET-PG:** * **Most common malignant tumor (Parotid/Minor Salivary):** Mucoepidermoid Carcinoma. * **Tumor with highest propensity for perineural invasion:** Adenoid Cystic Carcinoma (presents with "skip lesions"). * **Rule of 80s (Parotid):** 80% are in the parotid, 80% are benign, 80% are Pleomorphic Adenoma. * **Clinical Suspicion:** Any salivary gland mass associated with **Facial Nerve Palsy** is considered malignant until proven otherwise.

Practice by Chapter

Salivary Gland Diseases

Practice Questions

Thyroid Gland Disorders

Practice Questions

Parathyroid Gland Disorders

Practice Questions

Neck Masses Evaluation

Practice Questions

Oral Cavity Lesions

Practice Questions

Laryngeal Disorders

Practice Questions

Head and Neck Cancer

Practice Questions

Reconstructive Techniques in Head and Neck Surgery

Practice Questions

Surgical Management of Sleep Apnea

Practice Questions

Airway Management in Head and Neck Surgery

Practice Questions

Surgical Approaches to the Neck

Practice Questions

Neck Dissection Techniques

Practice Questions

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