Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 271: Laryngeal Papillomatosis is caused by which virus?

A. Human Papillomavirus (HPV) (Correct Answer)
B. Epstein-Barr Virus (EBV)
C. Cytomegalovirus (CMV)
D. Herpes Simplex Virus (HSV)

Explanation: **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**.

Question 272: All of the following statements regarding branchial cysts are true except?

A. Seen in mediastinum
B. 50-70% occur in lung (Correct Answer)
C. Are commonly infected
D. Multilocular

Explanation: **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).

Question 273: Which of the following structures are preserved in a functional radical neck dissection?

A. Internal jugular vein, Sternomastoid muscle, Lymph nodes, Accessory nerve
B. Sternomastoid muscle, Lymph nodes, Accessory nerve
C. Internal jugular vein, Accessory nerve (Correct Answer)
D. Internal jugular vein, Lymph nodes, Accessory nerve

Explanation: ### 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).

Question 274: Which sign is suggestive of malignant change in a parotid gland tumor?

A. Skin ulceration
B. Increasing pain
C. Facial palsy
D. All of the above (Correct Answer)

Explanation: 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.

Question 275: Which structure is most commonly damaged during surgery for a ranula?

A. Lingual artery
B. Lingual nerve
C. Submandibular duct (Correct Answer)
D. Sublingual duct

Explanation: **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.

Question 276: Mucoepidermoid carcinoma arises from which of the following cell types?

A. Epithelium
B. Myoepithelium
C. Acinus
D. Mucin secreting and epidermal cells (Correct Answer)

Explanation: **Explanation:** **Mucoepidermoid Carcinoma (MEC)** is the most common malignant tumor of the salivary glands in both adults and children. The name itself is a literal description of its cellular composition. **Why the correct answer is right:** MEC is a heterogeneous neoplasm characterized by a mixture of three distinct cell types: 1. **Mucin-secreting (Mucinous) cells:** Responsible for the "muco" component; these cells often form cystic spaces. 2. **Epidermoid (Squamous) cells:** Responsible for the "epidermoid" component; these cells show features of squamous differentiation (though keratin pearls are rare). 3. **Intermediate cells:** These are progenitor cells that can differentiate into either of the above types. The diagnosis depends on identifying this dual population of mucus-producing and squamous cells. **Why the incorrect options are wrong:** * **A. Epithelium:** While it is an epithelial tumor, this is too broad a term. All salivary gland tumors are epithelial, but MEC is specifically defined by its mixed cell population. * **B. Myoepithelium:** Myoepithelial cells are prominent in tumors like Pleomorphic Adenoma or Adenoid Cystic Carcinoma, but they do not define MEC. * **C. Acinus:** Acinar cells are the origin of **Acinic Cell Carcinoma**, which is characterized by cells containing zymogen granules, not mucin or squamous features. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Site:** Parotid gland (overall), but it is also the most common malignancy of the minor salivary glands (especially the palate). * **Grading:** Classified into Low, Intermediate, and High grade based on the ratio of cystic (mucinous) to solid (epidermoid) components. * **Genetics:** Frequently associated with the **t(11;19)(q21;p13)** translocation, resulting in the **CRTC1-MAML2** fusion gene. * **Clinical Presentation:** Low-grade tumors often mimic benign cysts, while high-grade tumors may present with rapid growth and facial nerve palsy.

Question 277: 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?

A. Radiotherapy
B. Segmental mandibulectomy
C. Marginal mandibulectomy involving removal of the outer table only (Correct Answer)
D. Marginal mandibulectomy involving removal of the upper half of the mandible

Explanation: **Explanation:** The management of mandibular involvement in buccal mucosa or alveolar squamous cell carcinoma (SCC) depends on the depth of invasion and the state of the mandible (dentate vs. edentulous). **Why Option C is the correct answer (NOT indicated):** In an **edentulous** elderly patient, the mandible undergoes significant resorption, leaving the inferior alveolar canal very close to the superior surface. A "marginal mandibulectomy involving the outer table only" is oncologically inadequate for alveolar infiltration. Furthermore, in edentulous patients, any marginal resection often leaves the remaining bone too thin and prone to pathological fractures. Therefore, a simple outer table resection is neither oncologically sound nor structurally viable in this scenario. **Analysis of other options:** * **Radiotherapy (A):** While surgery is the primary treatment for bone-infiltrating SCC, radiotherapy is often indicated as an adjuvant treatment post-surgery if there are positive margins, perineural invasion, or nodal metastasis. * **Segmental mandibulectomy (B):** This is the treatment of choice when there is gross cortical invasion or when the medullary space is involved, especially in the resorbed edentulous mandible where a marginal resection would compromise structural integrity. * **Marginal mandibulectomy (upper half) (D):** This is typically indicated for superficial/cortical invasion in **dentate** patients with sufficient bone height. In an edentulous patient, while technically an option for very early erosion, it is usually avoided in favor of segmental resection due to the high risk of fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Mandiublar Invasion:** If the tumor is fixed to the bone but no radiological erosion is seen, **Marginal Mandibulectomy** is preferred. * **Medullary Involvement:** If there is radiological evidence of marrow involvement, **Segmental Mandibulectomy** is mandatory. * **The Edentulous Factor:** Always remember that the edentulous mandible is "thin." Marginal resections are technically difficult and often contraindicated; segmental resection is the safer surgical oncological approach.

Question 278: In submandibular gland excision, all of the following nerves may be affected EXCEPT?

A. Lingual nerve
B. Hypoglossal nerve
C. Glossopharyngeal nerve (Correct Answer)
D. Mandibular division of trigeminal nerve

Explanation: **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.

Question 279: 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?

A. Lymphoma
B. Squamous cell carcinoma (Correct Answer)
C. Metastatic skin cancer
D. Benign mixed tumor

Explanation: **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.

Question 280: Recurrence is common in pleomorphic adenoma because of:

A. Metastasis
B. Incomplete capsule (Correct Answer)
C. Highly aggressive nature
D. All of the above

Explanation: **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.

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

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Surgical Approaches to the Neck

Practice Questions

Neck Dissection Techniques

Practice Questions

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