Head and Neck Surgery Practice Questions

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: All of the following statements regarding branchial cysts are true except?

50-70% occur in lung. **Explanation:** The question asks for the **false** statement regarding branchial cysts. Branchial cysts are congenital developmental defects arising from the remnants of the **second branchial cleft** (95% of cases). **Why Option B is the Correct Answer (The False Statement):** Branchial cysts are **cervical** lesions, not pulmonary ones. They are typically located in the upper neck at the junction of the upper third and middle third of the sternocleidomastoid muscle. They do **not** occur in the lungs. The statement "50-70% occur in lung" is factually incorrect and likely confuses branchial cysts with other congenital thoracic lesions like bronchogenic cysts. **Analysis of Other Options:** * **Option A (Seen in mediastinum):** While rare, branchial remnants can occasionally track deep into the neck or upper mediastinum depending on their embryological origin (especially those arising from the 3rd or 4th pouches). * **Option C (Are commonly infected):** This is a true clinical feature. Branchial cysts often remain asymptomatic until they become infected, usually following an upper respiratory tract infection (URTI), leading to sudden enlargement and pain. * **Option D (Multilocular):** While typically unilocular, branchial cysts can present as multilocular masses, especially if they have been subjected to recurrent infections and internal scarring. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Most common site is the **anterior border of the sternocleidomastoid muscle** at the level of the angle of the mandible. * **Lining:** Usually lined by stratified squamous epithelium. * **Fluid Characteristics:** Contains "straw-colored" fluid rich in **cholesterol crystals** (pathognomonic). * **Age:** Usually presents in late childhood or early adulthood (20s-30s). * **Treatment:** Complete surgical excision (Sistrunk procedure is for Thyroglossal cysts, do not confuse the two).

Q: Which of the following structures are preserved in a functional radical neck dissection?

Internal jugular vein, Accessory nerve. ### Explanation In Head and Neck Surgery, understanding the classification of neck dissections is high-yield for NEET-PG. The correct answer is **C (Internal jugular vein, Accessory nerve)** because a **Functional Neck Dissection (FND)**, popularized by Bocca, aims to remove all cervical lymph node groups (Levels I-V) while preserving non-lymphatic structures. #### 1. Why Option C is Correct A Functional Neck Dissection (often used interchangeably with **Modified Radical Neck Dissection Type I**) involves the preservation of three key non-lymphatic structures: 1. **Spinal Accessory Nerve (CN XI):** Preserves shoulder function (trapezius muscle). 2. **Internal Jugular Vein (IJV):** Maintains venous drainage. 3. **Sternocleidomastoid Muscle (SCM):** Maintains neck contour and protection of the carotid. #### 2. Why Other Options are Incorrect * **Options A, B, and D** are incorrect because they include **"Lymph nodes"** as a preserved structure. By definition, the primary goal of any neck dissection (Radical, Modified, or Functional) is the **complete removal** of the specified lymph node levels. Preserving lymph nodes would defeat the oncological purpose of the surgery. #### 3. Clinical Pearls for NEET-PG * **Radical Neck Dissection (RND):** The "Gold Standard" (Crile’s) where SCM, IJV, and Accessory nerve are all **removed**. * **Modified Radical Neck Dissection (MRND):** * **Type I:** Preserves Accessory Nerve. * **Type II:** Preserves Accessory Nerve + IJV. * **Type III (Functional):** Preserves Accessory Nerve + IJV + SCM. * **Selective Neck Dissection:** Only specific lymph node levels are removed (e.g., Supraomohyoid dissection for oral cavity cancers). * **Complication:** Injury to the Spinal Accessory nerve leads to "Shoulder Syndrome" (shoulder pain, drooping, and inability to abduct the arm above 90 degrees).

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: Which structure is most commonly damaged during surgery for a ranula?

Submandibular duct. **Explanation:** A **ranula** is a clinical term for a mucous extravasation cyst occurring in the floor of the mouth, typically arising from the **sublingual gland**. The definitive treatment is surgical excision of the cyst along with the involved sublingual gland to prevent recurrence. **1. Why Submandibular Duct is the Correct Answer:** The **submandibular duct (Wharton’s duct)** runs medially and superiorly to the sublingual gland as it travels forward to open at the sublingual papilla. During the dissection of a ranula or the removal of the sublingual gland, the duct is at high risk because it is often displaced or compressed by the cyst. Accidental ligation or trauma to the duct can lead to obstructive sialadenitis of the submandibular gland. **2. Analysis of Incorrect Options:** * **Lingual Nerve:** While the lingual nerve is in close proximity (it loops under the submandibular duct), it lies deeper and more posterior. While it is at risk, the duct is more superficial and directly related to the cyst wall, making it the most commonly injured structure. * **Lingual Artery:** This artery runs deep to the hyoglossus muscle. It is generally well-protected and not in the immediate surgical field of a superficial ranula excision. * **Sublingual Duct:** These are multiple small ducts (ducts of Rivinus) that actually contribute to the formation of the ranula; their "damage" or removal is an intended part of the procedure rather than a surgical complication. **Clinical Pearls for NEET-PG:** * **Plunging Ranula:** A ranula that herniates through the **mylohyoid muscle** into the submandibular space, presenting as a neck swelling. * **Treatment of Choice:** Complete excision of the ranula with the **ipsilateral sublingual gland**. * **Sialolithiasis:** The submandibular duct is the most common site for salivary stones (80%) due to its alkaline, calcium-rich secretions and uphill course.

Q: In submandibular gland excision, all of the following nerves may be affected EXCEPT?

Glossopharyngeal nerve. **Explanation:** The submandibular gland is located in the submandibular triangle, and its surgical excision requires careful dissection to avoid damaging adjacent neurovascular structures. **Why Glossopharyngeal Nerve (CN IX) is the correct answer:** The glossopharyngeal nerve exits the skull through the jugular foramen and descends deep to the styloid process, entering the pharynx between the superior and middle constrictor muscles. It is located **deep and superior** to the surgical field of a standard submandibular gland excision. Therefore, it is not at risk during this procedure. **Analysis of Incorrect Options:** * **Lingual Nerve:** This nerve lies superior to the gland and loops under the submandibular duct (Wharton’s duct). It is at high risk during the ligation of the duct. * **Hypoglossal Nerve (CN XII):** This nerve forms the floor of the submandibular triangle (lying on the hyoglossus muscle). It is situated deep to the gland and can be injured during deep dissection. * **Mandibular division of Trigeminal Nerve (Marginal Mandibular Nerve):** This is a branch of the **Facial Nerve (CN VII)**, not the trigeminal nerve (though the option wording is a common distractor). The marginal mandibular nerve 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. **High-Yield Clinical Pearls for NEET-PG:** * **Safe Incision:** To protect the marginal mandibular nerve, the skin incision should be made **at least 2 cm (two finger-breadths) below the lower border of the mandible**. * **Nerve Relationship:** Remember the "double crossing"—the lingual nerve crosses the submandibular duct twice. * **Ganglion:** The submandibular ganglion (parasympathetic) is suspended from the lingual nerve and must be detached to remove the gland.

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.

Question 1

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 2

All of the following statements regarding branchial cysts are true except?

Accepted Answer

50-70% occur in lung

Answer

Seen in mediastinum

Answer

Are commonly infected

Answer

Multilocular

Question 3

Which of the following structures are preserved in a functional radical neck dissection?

Accepted Answer

Internal jugular vein, Accessory nerve

Answer

Internal jugular vein, Sternomastoid muscle, Lymph nodes, Accessory nerve

Answer

Sternomastoid muscle, Lymph nodes, Accessory nerve

Answer

Internal jugular vein, Lymph nodes, Accessory nerve

Question 4

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 5

Which structure is most commonly damaged during surgery for a ranula?

Accepted Answer

Submandibular duct

Answer

Lingual artery

Answer

Lingual nerve

Answer

Sublingual duct

Question 6

Mucoepidermoid carcinoma arises from which of the following cell types?

Accepted Answer

Mucin secreting and epidermal cells

Answer

Epithelium

Answer

Myoepithelium

Answer

Acinus

Question 7

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 8

In submandibular gland excision, all of the following nerves may be affected EXCEPT?

Accepted Answer

Glossopharyngeal nerve

Answer

Lingual nerve

Answer

Hypoglossal nerve

Answer

Mandibular division of trigeminal nerve

Question 9

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 10

Recurrence is common in pleomorphic adenoma because of:

Accepted Answer

Incomplete capsule

Answer

Metastasis

Answer

Highly aggressive nature

Answer

All of the above

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?