Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 261: A young patient presents with a midline, tender swelling in the neck that occurred after an attack of sore throat. What is the most likely diagnosis?

A. Acute thyroiditis
B. Thyroglossal cyst
C. Subacute thyroiditis (Correct Answer)
D. Toxic goiter

Explanation: **Explanation:** **Subacute Thyroiditis (De Quervain’s Thyroiditis)** is the most likely diagnosis. The classic presentation involves a **painful, tender midline neck swelling** that typically follows a **viral upper respiratory tract infection** (sore throat). It is an inflammatory condition, likely post-viral, characterized by the destruction of thyroid follicles and the release of preformed thyroid hormones. **Why the other options are incorrect:** * **Acute Thyroiditis:** This is a rare bacterial infection (usually *S. aureus*). While it presents with severe pain and fever, it is typically associated with a pyriform sinus fistula and presents as an abscess rather than a post-viral swelling. * **Thyroglossal Cyst:** While this is a midline swelling, it is typically **painless** unless infected. It characteristically moves upward on protrusion of the tongue, which is not mentioned here. * **Toxic Goiter:** Conditions like Graves' disease present with features of hyperthyroidism and a diffuse, non-tender goiter. Pain and tenderness are not features of toxic goiter. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic Feature:** Elevated ESR (often >50-100 mm/hr) with low radioactive iodine uptake (RAIU) due to follicular damage. * **Histology:** Presence of **multinucleated giant cells** and granulomatous inflammation. * **Treatment:** Primarily symptomatic with NSAIDs; steroids are used for severe pain. It is usually self-limiting. * **Triad to remember:** Post-viral + Exquisite tenderness + High ESR = Subacute Thyroiditis.

Question 262: Regarding cystic disease of the breast, which one of the following statements is true?

A. Common in 25 years of age
B. Excision is the treatment
C. May turn into malignant
D. Aspiration is the treatment (Correct Answer)

Explanation: **Explanation:** Cystic disease of the breast, often part of **Fibrocystic Change (ANDI - Aberrations of Normal Development and Involution)**, is a benign condition characterized by fluid-filled sacs resulting from the involution of breast lobules. **Why Option D is correct:** **Fine Needle Aspiration (FNA)** is both diagnostic and therapeutic. If the aspirated fluid is non-bloody and the lump disappears completely without recurrence, no further treatment is required. This makes aspiration the primary management strategy for symptomatic or large cysts. **Why other options are incorrect:** * **Option A:** Cystic disease is most common in the **perimenopausal age group (35–50 years)**, not 25. It is rare after menopause unless the patient is on Hormone Replacement Therapy (HRT). * **Option B:** Excision is not the first-line treatment. Surgery is only indicated if the cyst recurs repeatedly after aspiration, contains blood-stained fluid, or shows a residual solid mass (intracystic papilloma/carcinoma). * **Option C:** Simple cysts are **benign** and do not carry an increased risk of malignancy. Only complex cysts with solid components or proliferative changes with atypia (found on biopsy) increase the risk of future breast cancer. **NEET-PG High-Yield Pearls:** * **Triple Assessment:** Clinical examination, Imaging (Ultrasound is preferred for cysts), and Pathology (FNA/Core Biopsy). * **Blue-Domed Cysts of Bloodgood:** A classic pathological description of large, tense cysts containing brownish-blue fluid. * **Management Rule:** If the fluid is bloody or the mass persists after aspiration, a core needle biopsy is mandatory to rule out malignancy.

Question 263: All of the following are approaches to the Temporomandibular joint, except?

A. Hind's retromandibular approach
B. Gillie's temporal approach (Correct Answer)
C. Alkayat-Bramley preauricular incision
D. Endaural approach

Explanation: **Explanation:** The correct answer is **Gillie’s temporal approach** because it is not used to access the Temporomandibular Joint (TMJ) itself; rather, it is a specific surgical technique used for the **reduction of isolated zygomatic arch fractures**. ### Why Gillie’s Approach is the Exception: In Gillie’s approach, an incision is made in the temporal region (within the hairline), and a plane is created deep to the **temporal fascia** but superficial to the **temporalis muscle**. An elevator (e.g., Bristow’s or Rowe’s) is passed down this plane to reach the medial aspect of the zygomatic arch to "pop" the fracture back into place. It does not provide visualization or surgical access to the TMJ capsule or disc. ### Evaluation of Other Options: * **Hind’s Retromandibular Approach:** This provides excellent access to the posterior border of the ramus and the condylar process. It is commonly used for ORIF (Open Reduction Internal Fixation) of subcondylar fractures. * **Alkayat-Bramley Preauricular Incision:** This is a modification of the standard preauricular approach. It uses a question-mark-shaped incision to provide wide exposure of the TMJ and zygomatic arch while protecting the upper branches of the facial nerve. It is considered the "gold standard" for TMJ ankylosis surgery. * **Endaural Approach:** The incision is made within the external auditory meatus. It provides direct access to the joint while hiding the scar within the ear canal, though it carries a risk of meatal stenosis. ### High-Yield Clinical Pearls for NEET-PG: * **Most common approach to TMJ:** Preauricular approach. * **Nerve at risk during TMJ surgery:** Facial nerve (specifically the temporal and zygomatic branches). * **Gillie’s Approach Landmark:** The incision is made 2.5 cm superior and anterior to the helix, staying deep to the deep temporal fascia to avoid the temporal branch of the facial nerve.

Question 264: Which of the following masses develops along the lines of embryological fusion in the floor of the mouth?

A. Cholesteatoma
B. Dermoid cyst (Correct Answer)
C. Glomus tumor
D. Neurofibroma

Explanation: ### Explanation **Correct Answer: B. Dermoid cyst** **Mechanism and Concept:** Dermoid cysts in the head and neck are developmental malformations that occur when **ectodermal elements** are trapped during the fusion of the first and second branchial arches in the midline. In the floor of the mouth, they specifically develop along the **lines of embryological fusion** (the midline). Pathologically, they are lined by stratified squamous epithelium and contain skin appendages such as hair follicles, sebaceous glands, and sweat glands. **Analysis of Incorrect Options:** * **A. Cholesteatoma:** This is a non-neoplastic, keratinizing squamous epithelial lesion found in the middle ear or mastoid. While it contains keratin, it does not arise from midline embryological fusion in the oral cavity. * **C. Glomus tumor (Paraganglioma):** These are highly vascular tumors arising from chemoreceptor cells (e.g., carotid body or glomus jugulare). They are not developmental cysts related to fusion lines. * **D. Neurofibroma:** These are benign nerve sheath tumors arising from peripheral nerves (Schwann cells and fibroblasts). They are associated with Neurofibromatosis Type 1 and do not follow embryological fusion patterns. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** Dermoid cysts typically present as a slow-growing, painless, **midline** submental or sublingual swelling. * **Anatomical Landmark:** Their position relative to the **mylohyoid muscle** determines their presentation: * *Above mylohyoid:* Sublingual swelling (elevates the tongue). * *Below mylohyoid:* Submental swelling (presents as a "double chin"). * **Diagnostic Sign:** On palpation, they often have a characteristic **"doughy" consistency** due to the presence of sebum and keratin. * **Differential Diagnosis:** Must be distinguished from a **Ranula** (which is usually lateral and has a "blue" translucent appearance) and a **Thyroglossal duct cyst** (which moves with protrusion of the tongue).

Question 265: Which neck swelling moves on swallowing?

A. Submandibular salivary gland
B. Thyroid gland (Correct Answer)
C. Supraclavicular lymph gland
D. Sternomastoid tumour

Explanation: **Explanation:** The **Thyroid gland** is the correct answer because of its unique anatomical relationship with the **pretracheal fascia**. The thyroid is enclosed within this fascia, which is firmly attached to the **cricoid cartilage** and the **oblique line of the thyroid cartilage**. During deglutition (swallowing), the larynx and trachea are elevated by the suprahyoid muscles; because the thyroid is anchored to these structures via the pretracheal fascia (specifically the Suspensory Ligament of Berry), it moves upward along with them. **Analysis of Incorrect Options:** * **Submandibular salivary gland:** Located in the submandibular triangle, it is not attached to the laryngeal framework or the pretracheal fascia. While it may move slightly with jaw movement, it does not move with swallowing. * **Supraclavicular lymph gland:** These are located in the posterior triangle or the root of the neck and are not associated with the visceral compartment of the neck. * **Sternomastoid tumour:** This is a fibromatosis of the sternocleidomastoid muscle (often seen in congenital muscular torticollis). It is located within the carotid sheath or muscle belly and is independent of the swallowing mechanism. **Clinical Pearls for NEET-PG:** 1. **Exceptions:** Two other swellings move with swallowing: **Thyroglossal cysts** (which also move with **protrusion of the tongue** due to their attachment to the hyoid bone) and **Subhyoid bursitis**. 2. **Fixed Thyroid:** If a thyroid swelling does *not* move with swallowing, it suggests **malignant infiltration** into surrounding structures or **Riedel’s thyroiditis**. 3. **Laryngocele:** This may also move with swallowing but is typically resonant on percussion.

Question 266: With respect to surgical repair of cleft palate, the soft palate is first repaired. What is the ideal age for this procedure?

A. 12 months
B. 9 months
C. 6 months (Correct Answer)
D. 3 months

Explanation: **Explanation:** The surgical repair of a cleft palate (Palatoplasty) is strategically timed to balance two competing factors: maximizing normal speech development and minimizing interference with maxillary (mid-face) growth. **Why 6 months is correct:** Current surgical protocols, particularly the **two-stage repair**, advocate for the repair of the **soft palate at 6 months of age**. The soft palate contains the musculature (levator veli palatini) essential for velopharyngeal competence. Early repair (at 6 months) allows the infant to develop the necessary muscle control for normal phonation and swallowing before they begin complex speech patterns. The hard palate is often delayed until 15–18 months to prevent early scarring that could restrict maxillary growth and lead to mid-face retrusion. **Analysis of Incorrect Options:** * **3 months (Option D):** This is the traditional age for **Cleft Lip repair** (Rule of 10s). Repairing the palate at 3 months is technically difficult due to the small size of the oral cavity and carries a higher anesthetic risk. * **9 months & 12 months (Options B & A):** While many centers perform a single-stage total palate repair between 9 and 12 months, the specific question asks for the repair of the **soft palate first**. In a staged approach, 6 months is the gold standard to ensure optimal speech outcomes. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of 10s (Millard’s Criteria for Cleft Lip):** 10 weeks old, 10 lbs weight, 10 g/dL Hemoglobin. * **Speech Development:** The primary goal of palatoplasty is speech; the primary goal of cheiloplasty (lip repair) is aesthetics and feeding. * **Common Muscle Involved:** The **Levator veli palatini** is the most important muscle to reconstruct during palatoplasty. * **Otitis Media:** Children with cleft palate are prone to **Otitis Media with Effusion** due to Eustachian tube dysfunction (dysfunction of the Tensor veli palatini).

Question 267: What is the primary causative factor for myofascial pain dysfunction syndrome of the temporomandibular joint (TMJ)?

A. Infratemporal space infection
B. Auriculotemporal neuritis
C. Muscular overextension and overcontraction (Correct Answer)
D. Otitis media

Explanation: **Explanation:** **Myofascial Pain Dysfunction Syndrome (MPDS)** is the most common cause of temporomandibular joint (TMJ) pain. Unlike internal derangements of the joint, MPDS is primarily a **psychophysiological disorder** involving the muscles of mastication rather than the joint structures themselves. **Why Option C is Correct:** The primary causative factor is **muscular overextension and overcontraction**, often triggered by psychological stress. This leads to parafunctional habits such as **bruxism** (teeth grinding) or clenching. These repetitive actions result in muscle fatigue, spasms, and the formation of "trigger points," which manifest as dull, aching pain in the preauricular region and restricted jaw movement. **Why Other Options are Incorrect:** * **Option A (Infratemporal space infection):** While this can cause trismus (lockjaw) and pain, it is an acute bacterial process characterized by fever and swelling, not the chronic functional etiology seen in MPDS. * **Option B (Auriculotemporal neuritis):** The auriculotemporal nerve provides sensory innervation to the TMJ, but primary neuritis is rare and does not account for the muscular spasms central to MPDS. * **Option D (Otitis media):** This is an inflammatory condition of the middle ear. While it can cause referred pain to the TMJ area, it does not involve the masticatory muscle dysfunction characteristic of MPDS. **High-Yield Clinical Pearls for NEET-PG:** * **Laskin’s Diagnostic Criteria:** MPDS is diagnosed by the presence of unilateral pain, muscle tenderness, clicking sounds (sometimes), and limitation of jaw opening. * **Management:** Treatment is conservative, focusing on **stress reduction**, NSAIDs, muscle relaxants, and soft occlusal splints (night guards). * **Demographics:** It is most frequently seen in young females (20–40 years).

Question 268: A 65-year-old smoker presents with hoarseness, hemoptysis, and a hard painless lump in the left supraclavicular fossa. What is the most appropriate next diagnostic step?

A. Open biopsy of the neck lump (Correct Answer)
B. Radical neck dissection
C. Fine needle aspiration cytology
D. Trial of anti-tuberculous therapy

Explanation: ### Explanation The clinical presentation of a **65-year-old smoker** with **hoarseness and hemoptysis** strongly suggests a primary malignancy of the upper aerodigestive tract (likely laryngeal or lung carcinoma). The hard, painless lump in the left supraclavicular fossa is a classic description of **Troisier’s sign**, indicating a metastatic supraclavicular lymph node (Virchow’s node). **Why Option A is Correct:** In the context of a suspected metastatic neck node where the primary site is not immediately obvious or requires tissue architecture for definitive subtyping (especially if FNAC is inconclusive or if lymphoma is a differential), an **open biopsy** provides the most definitive histological diagnosis. While FNAC is often the *initial* step in many protocols, the specific framing of this question (often based on classic surgical teaching) emphasizes that for a definitive diagnosis of a hard, suspicious supraclavicular mass in an elderly smoker, histological confirmation via open biopsy is the gold standard to plan further management. **Why the other options are incorrect:** * **B. Radical neck dissection:** This is a major therapeutic surgical procedure, not a diagnostic step. It is only performed after a tissue diagnosis of malignancy is confirmed. * **C. Fine needle aspiration cytology (FNAC):** While often used first in clinical practice due to its non-invasive nature, it provides only cytological details. If the question implies a definitive diagnostic step for a hard, fixed node, open biopsy is superior for architectural detail. * **D. Trial of anti-tuberculous therapy:** This is inappropriate and dangerous in an elderly smoker with red-flag symptoms (hoarseness/hemoptysis), as it delays the diagnosis of an underlying malignancy. **Clinical Pearls for NEET-PG:** * **Troisier’s Sign:** Enlargement of the left supraclavicular node (Virchow’s node) due to metastatic spread via the thoracic duct. * **Rule of 80:** In non-thyroid neck masses in adults, 80% are neoplastic; of those, 80% are malignant; of those, 80% are metastatic (usually from a primary above the clavicle). * **Hoarseness + Neck Lump:** Always rule out laryngeal or hypopharyngeal carcinoma.

Question 269: What is the most common site of squamous cell carcinoma?

A. Floor of the mouth
B. Tongue (Correct Answer)
C. Buccal mucosa
D. Lip

Explanation: **Explanation:** In the context of oral cavity cancers, **Squamous Cell Carcinoma (SCC)** is the most common histological type, accounting for over 90% of cases. Globally and across most surgical textbooks (including Bailey & Love), the **tongue** (specifically the anterior two-thirds or lateral borders) is identified as the most common site for oral SCC. **Why Tongue is Correct:** The lateral borders and the ventral surface of the tongue are highly susceptible due to the thin, non-keratinized epithelium and the pooling of carcinogens (like tobacco and alcohol) in the adjacent gutters. It is highly vascular and has a rich lymphatic drainage, leading to early nodal metastasis. **Analysis of Incorrect Options:** * **Floor of the mouth:** This is the second most common site. While it is a high-risk area due to the "reservoir effect" of saliva-borne carcinogens, its incidence is statistically lower than that of the tongue. * **Buccal mucosa:** This is the most common site specifically in regions where **betel quid (pan) chewing** is rampant (e.g., parts of India). However, unless the question specifies "in the Indian subcontinent" or "associated with betel chewing," the tongue remains the standard universal answer. * **Lip:** SCC of the lip is more common in Western populations with high sun exposure (UV radiation), typically affecting the lower lip. It has a better prognosis than intraoral SCC. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site (Overall Oral Cavity):** Tongue (Lateral border). * **Most common site in India:** Buccal mucosa (due to tobacco/betel nut chewing). * **Premalignant lesions:** Erythroplakia has a much higher transformation rate to SCC than Leukoplakia. * **Lymphatic Spread:** Tongue SCC often presents with early metastasis to Level II (upper deep cervical) nodes. * **Field Cancerization:** This concept explains why patients with one oral SCC are at high risk for developing a second primary tumor in the upper aerodigestive tract.

Question 270: What is the commonest treatment for a Branchial cyst?

A. Cystectomy
B. Aspiration
C. Excision (Correct Answer)
D. No treatment

Explanation: **Explanation:** A **Branchial cyst** is a congenital epithelial cyst arising from the remnants of the second branchial cleft (95% of cases). It typically presents as a soft, fluctuant, non-transilluminant mass at the junction of the upper third and middle third of the sternocleidomstoid muscle. **Why Excision is the Correct Answer:** The definitive treatment for a branchial cyst is **complete surgical excision**. This is necessary because the cyst has a high propensity for recurrent infections and can lead to fistula formation if left untreated. During surgery, care must be taken to identify and preserve the carotid vessels, as the cyst is typically located in the carotid triangle, deep to the cervical fascia. **Analysis of Incorrect Options:** * **A. Cystectomy:** While technically similar to excision, "Excision" is the preferred surgical terminology for the complete removal of the cyst along with its lining to prevent recurrence. * **B. Aspiration:** Aspiration is only used as a diagnostic tool (to find cholesterol crystals) or to temporarily relieve pressure in an infected cyst. It is never curative, as the epithelial lining remains, leading to inevitable recurrence. * **D. No treatment:** Conservative management is not recommended due to the high risk of secondary infection (abscess formation) and the rare risk of branchiogenic carcinoma in older adults. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Most common at the anterior border of the upper 1/3rd of the Sternocleidomstoid muscle. * **Pathognomonic Finding:** Aspiration of the cyst fluid typically reveals **cholesterol crystals**. * **Lining:** Usually lined by stratified squamous epithelium. * **Differential Diagnosis:** Must be differentiated from a cold abscess (TB) or Carotid Body Tumor. * **Age:** Usually presents in late childhood or early adulthood (2nd–3rd decade).

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

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Surgical Management of Sleep Apnea

Practice Questions

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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