Head and Neck Surgery Practice Questions

Q: What is the commonest treatment for a Branchial cyst?

Excision. **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).

Q: Laryngeal Papillomatosis is caused by which virus?

Human Papillomavirus (HPV). **Explanation:** **Laryngeal Papillomatosis** (also known as Recurrent Respiratory Papillomatosis or RRP) is a benign neoplastic condition characterized by the growth of multiple finger-like projections (papillomas) in the respiratory tract, most commonly on the true vocal cords. 1. **Why HPV is Correct:** The condition is caused by the **Human Papillomavirus (HPV)**. Specifically, **HPV types 6 and 11** are responsible for over 90% of cases. These are "low-risk" types that cause benign epithelial proliferation rather than malignancy. In children (Juvenile-onset RRP), the virus is typically acquired during birth via an infected maternal birth canal. In adults (Adult-onset RRP), it is often associated with orogenital contact. 2. **Why Other Options are Incorrect:** * **EBV (Epstein-Barr Virus):** Primarily associated with Nasopharyngeal Carcinoma, Burkitt’s Lymphoma, and Infectious Mononucleosis. * **CMV (Cytomegalovirus):** Causes retinitis or esophagitis in immunocompromised patients and congenital infections, but not laryngeal growths. * **HSV (Herpes Simplex Virus):** Causes vesicular lesions (cold sores or genital herpes) and encephalitis, not papillomatous growths. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** True vocal cords (transition zone between squamous and ciliated epithelium). * **Triad of Symptoms:** Hoarseness of voice, stridor, and respiratory distress. * **Treatment of Choice:** CO2 Laser excision or Microdebridement. * **Adjuvant Therapy:** Cidofovir (antiviral) is often used in recalcitrant cases. * **Malignant Transformation:** Rare, but if it occurs (usually to Squamous Cell Carcinoma), it is often associated with **HPV types 16 and 18**.

Q: A patient with oral cancer has an ipsilateral lymph node measuring 2 cm, single in number with capsular spread. According to TNM staging, what is this classified as?

N3. ### Explanation The correct answer is **N3** (specifically **N3a** or **N3b** depending on the presence of Extranodal Extension). #### 1. Why N3 is Correct According to the **AJCC 8th Edition** for Oral Cavity Cancers, the staging of cervical lymph nodes has been updated to include **Extranodal Extension (ENE)**, also known as capsular spread. * **Clinical N3b:** Defined as a single or multiple nodes with **clinically positive ENE**. * **Pathological N3b:** Defined as a single or multiple nodes with **pathologically proven ENE**. Even though the node is single and only 2 cm (which would traditionally be N1), the presence of **capsular spread (ENE)** automatically upgrades the stage to **N3b**. ENE is a significant prognostic factor indicating a higher risk of regional recurrence and distant metastasis. #### 2. Why Other Options are Wrong * **Nx:** This is used when regional lymph nodes cannot be assessed. In this case, the node has been measured and evaluated. * **N1:** This is a single ipsilateral node $\leq$ 3 cm **without** extranodal extension. * **N2:** This category includes nodes between 3–6 cm, or multiple nodes, but specifically **without** extranodal extension. #### 3. High-Yield Clinical Pearls for NEET-PG * **ENE Definition:** Extension of tumor through the lymph node capsule into the surrounding connective tissue. * **AJCC 7th vs 8th Edition:** The most critical change in the 8th edition for Head and Neck cancers is the incorporation of **ENE** into N-staging and **Depth of Invasion (DOI)** into T-staging. * **N3a:** A node > 6 cm without ENE. * **N3b:** Any node (regardless of size or number) with ENE. * **Management:** The presence of ENE is an absolute indication for **adjuvant chemoradiotherapy** post-surgery.

Q: Eminectomy is done for the treatment of which of the following conditions?

TMJ dislocation. **Explanation:** **Eminectomy** is a surgical procedure involving the removal of the **articular eminence** of the temporal bone. It is primarily indicated for the treatment of **chronic recurrent temporomandibular joint (TMJ) dislocation**. **Why Option B is Correct:** In chronic recurrent dislocation, the mandibular condyle translates too far forward beyond the articular eminence and becomes trapped, unable to return to the glenoid fossa. By performing an eminectomy, the mechanical barrier (the eminence) is removed. This allows the condyle to move freely in and out of the fossa without getting locked, effectively preventing future episodes of painful dislocation. **Why Other Options are Incorrect:** * **TMJ Ankylosis (Option A):** This involves the fusion of the joint (fibrous or bony). The standard surgical treatments are **gap arthroplasty** or **interpositional arthroplasty**, not eminectomy. * **Coronoid Fracture (Option C):** Fractures of the coronoid process are usually managed conservatively or via **open reduction and internal fixation (ORIF)** if displaced. Eminectomy does not address the coronoid process or its fractures. **High-Yield Clinical Pearls for NEET-PG:** * **First-line management** for acute TMJ dislocation is manual reduction (Nelaton’s maneuver). * **Dautrey’s Procedure:** An alternative to eminectomy where the zygomatic arch is fractured and displaced downward to create a *larger* barrier to prevent the condyle from slipping forward. * **Conservative management** for recurrent dislocation includes sclerosing agents or botulinum toxin injections into the lateral pterygoid muscle. * **Key Anatomy:** The articular eminence forms the anterior boundary of the glenoid fossa.

Q: Which sign is suggestive of malignant change in a parotid gland tumor?

All of the above. In parotid gland tumors, the majority (80%) are benign, such as Pleomorphic Adenoma. However, certain clinical "red flags" strongly suggest a transition to or the primary presence of malignancy (e.g., Mucoepidermoid carcinoma or Adenoid cystic carcinoma). **Explanation of Options:** * **Facial Nerve Palsy (Option C):** This is the **most specific** clinical indicator of malignancy. Benign tumors are typically well-encapsulated and displace the facial nerve. Malignant tumors are infiltrative; they invade the nerve sheath or axons, leading to lower motor neuron facial paralysis. * **Increasing Pain (Option B):** While benign tumors are usually painless, slow-growing masses, malignancy often causes pain due to perineural invasion (especially common in Adenoid cystic carcinoma) or rapid expansion causing pressure on the capsule. * **Skin Ulceration (Option A):** This indicates advanced local invasion. Malignant cells infiltrate the overlying subcutaneous tissue and dermis, leading to fixity and eventual breakdown of the skin. **Why "All of the Above" is Correct:** All three features represent **infiltrative behavior**, which is the hallmark of malignancy. Benign tumors respect anatomical boundaries, whereas malignant tumors destroy them. **High-Yield Clinical Pearls for NEET-PG:** * **Most common parotid malignancy:** Mucoepidermoid carcinoma. * **Malignancy with highest propensity for perineural invasion:** Adenoid cystic carcinoma. * **Hard, fixed mass with cervical lymphadenopathy:** Highly suggestive of malignancy. * **Rapid increase in size** of a long-standing stable parotid mass suggests **Carcinoma ex-pleomorphic adenoma**. * **Investigation of choice:** FNAC (Fine Needle Aspiration Cytology). Incisional biopsy is strictly contraindicated to prevent tumor seeding and Frey’s syndrome.

Q: A 63-year-old bartender presents with a painful sore on his tongue and an ulcerated lesion on his tongue with a mass in the submandibular gland triangle. What is the most likely diagnosis?

Squamous cell carcinoma. **Explanation:** The clinical presentation of a chronic, painful ulcerated lesion on the tongue in an elderly patient, associated with a mass in the submandibular triangle (Level IB lymph node), is a classic hallmark of **Squamous Cell Carcinoma (SCC)** of the oral cavity. **1. Why Squamous Cell Carcinoma is correct:** SCC accounts for over 90% of all oral cavity malignancies. The tongue is the most common site. The "mass in the submandibular triangle" represents **regional lymphatic metastasis**, which is common due to the rich lymphatic drainage of the tongue. Risk factors often include chronic irritation, tobacco, and alcohol (notably, the patient’s profession as a bartender suggests potential exposure to these). **2. Why the other options are incorrect:** * **Lymphoma:** While it can involve Waldeyer’s ring (tonsils), it rarely presents as a primary ulcerated lesion on the mobile tongue. It usually presents as systemic lymphadenopathy or a submucosal mass. * **Metastatic skin cancer:** While skin cancers (like melanoma) can metastasize to neck nodes, they rarely present as a primary ulcerated lesion on the tongue. * **Benign mixed tumor (Pleomorphic Adenoma):** This is the most common tumor of the salivary glands. However, it presents as a slow-growing, painless, firm swelling without mucosal ulceration or painful sores. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Oral SCC:** Lateral border of the tongue. * **Premalignant lesions:** Erythroplakia has a much higher transformation rate to SCC than Leukoplakia. * **Staging:** The presence of a neck mass (nodal metastasis) is the most important prognostic factor in head and neck SCC. * **Field Cancerization:** This concept explains why patients with one oral SCC are at high risk for developing synchronous or metachronous primary tumors in the upper aerodigestive tract.

Q: Recurrence is common in pleomorphic adenoma because of:

Incomplete capsule. **Explanation:** Pleomorphic adenoma (Mixed tumor) is the most common benign tumor of the salivary glands, most frequently involving the parotid gland. Despite being benign, it has a notorious reputation for recurrence if not managed correctly. **Why "Incomplete Capsule" is correct:** The primary reason for recurrence is the tumor’s **pseudocapsule**. Histologically, the capsule is often thin, incomplete, or breached by finger-like projections of tumor cells called **pseudopods**. If a surgeon performs a simple "enucleation" (shelling out the tumor), these microscopic extensions are left behind in the gland, leading to multifocal recurrence. To prevent this, the standard treatment is **Superficial Parotidectomy**, ensuring a margin of healthy tissue is removed along with the tumor. **Analysis of Incorrect Options:** * **A. Metastasis:** Pleomorphic adenoma is a benign tumor. While a rare entity called "Metastasizing Pleomorphic Adenoma" exists, it is an exception and not the reason for standard clinical recurrence. * **C. Highly aggressive nature:** These tumors are typically slow-growing and painless. They are not inherently aggressive; the recurrence is a result of surgical inadequacy due to the anatomical nature of the capsule. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Superficial lobe of the parotid gland. * **Histology:** Characterized by a "mixed" appearance—epithelial elements and mesenchymal-like stroma (myxoid, chondroid, or osteoid). * **Risk of Malignancy:** Approximately 3–5% can transform into **Carcinoma ex Pleomorphic Adenoma** (suspect if a long-standing lump suddenly grows rapidly). * **Treatment of Choice:** Superficial parotidectomy with preservation of the Facial Nerve. Enucleation is contraindicated.

Q: Which of the following lesions has a radiographic soap bubble appearance, with a characteristic feature of 'pumping action'?

Central hemangioma. **Explanation:** The correct answer is **Central Hemangioma**. This is a rare intraosseous vascular malformation, most commonly involving the mandible. **1. Why Central Hemangioma is correct:** Radiographically, central hemangiomas often present as a multilocular radiolucency with a **"soap bubble," "honeycomb," or "sunburst" appearance**. The pathognomonic clinical feature mentioned is the **"pumping action" or "pumping phenomenon."** This occurs because the lesion is highly vascular and under arterial pressure; if a needle is inserted or pressure is applied, the plunger of the syringe may be pushed back spontaneously, or the tooth within the lesion may exhibit a rhythmic pulsation. **2. Why other options are incorrect:** * **Ameloblastoma:** While it classically presents with a "soap bubble" or "honeycomb" appearance, it is a benign epithelial tumor, not a vascular one. It lacks the pulsatile "pumping action." * **Central Giant Cell Granuloma (CGCG):** This typically shows a multilocular radiolucency with wispy, ill-defined septations. It does not exhibit vascular pulsations. * **Odontogenic Keratocyst (OKC):** Known for its characteristic growth along the internal aspect of the jaw (anteroposterior expansion) with minimal cortical expansion, it does not show the pumping phenomenon. **High-Yield Pearls for NEET-PG:** * **Aspiration is mandatory:** Always aspirate any suspected multilocular radiolucency before biopsy to rule out central hemangioma, as surgical intervention can lead to life-threatening hemorrhage. * **Radiographic variants:** Central hemangiomas can also show a **"Spoke-wheel"** appearance or **"Sunray"** appearance (radiating striae from a central point). * **Phleboliths:** The presence of small, rounded calcifications (phleboliths) within soft tissues is a diagnostic clue for vascular lesions.

Question 1

What is the commonest treatment for a Branchial cyst?

Accepted Answer

Excision

Answer

Cystectomy

Answer

Aspiration

Answer

No treatment

Question 2

Laryngeal Papillomatosis is caused by which virus?

Accepted Answer

Human Papillomavirus (HPV)

Answer

Epstein-Barr Virus (EBV)

Answer

Cytomegalovirus (CMV)

Answer

Herpes Simplex Virus (HSV)

Question 3

A patient with oral cancer has an ipsilateral lymph node measuring 2 cm, single in number with capsular spread. According to TNM staging, what is this classified as?

Accepted Answer

N3

Answer

Nx

Answer

N1

Answer

N2

Question 4

Eminectomy is done for the treatment of which of the following conditions?

Accepted Answer

TMJ dislocation

Answer

TMJ ankylosis

Answer

Coronoid fracture

Answer

All of the above

Question 5

Which sign is suggestive of malignant change in a parotid gland tumor?

Accepted Answer

All of the above

Answer

Skin ulceration

Answer

Increasing pain

Answer

Facial palsy

Question 6

An edentulous elderly male presents with squamous cell carcinoma of the buccal mucosa that has infiltrated the alveolus. Which of the following is NOT indicated in the treatment plan?

Accepted Answer

Marginal mandibulectomy involving removal of the outer table only

Answer

Radiotherapy

Answer

Segmental mandibulectomy

Answer

Marginal mandibulectomy involving removal of the upper half of the mandible

Question 7

A 63-year-old bartender presents with a painful sore on his tongue and an ulcerated lesion on his tongue with a mass in the submandibular gland triangle. What is the most likely diagnosis?

Accepted Answer

Squamous cell carcinoma

Answer

Lymphoma

Answer

Metastatic skin cancer

Answer

Benign mixed tumor

Question 8

Recurrence is common in pleomorphic adenoma because of:

Accepted Answer

Incomplete capsule

Answer

Metastasis

Answer

Highly aggressive nature

Answer

All of the above

Question 9

Which of the following lesions has a radiographic soap bubble appearance, with a characteristic feature of 'pumping action'?

Accepted Answer

Central hemangioma

Answer

Central Giant Cell Granuloma (CGCG)

Answer

Ameloblastoma

Answer

Odontogenic keratocyst (OKC)

Question 10

What does a supraomohyoid neck dissection entail?

Accepted Answer

Removal of lymph nodes from levels I to III

Answer

Removal of lymph nodes from levels I to V

Answer

Removal of lymph nodes from levels I to V along with the internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve

Answer

Removal of lymph nodes from levels I to III along with the internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?