Head and Neck Surgery Practice Questions

Q: A patient presents with a 1.5 cm fibroma on the floor of the mouth. What type of biopsy is recommended?

Incisional biopsy. **Explanation:** The management of oral lesions depends primarily on the size and clinical suspicion of the lesion. For a **1.5 cm fibroma on the floor of the mouth**, an **incisional biopsy** is the recommended approach. The floor of the mouth is a high-risk area for malignancy and contains vital structures (submandibular ducts, lingual nerves). According to surgical principles, any oral lesion larger than **1 cm** or those with suspicious features should undergo an incisional biopsy first. This allows for a definitive histological diagnosis without performing an extensive primary surgery that might compromise margins if the lesion proves to be malignant. **Analysis of Options:** * **Excisional Biopsy (Incorrect):** This is reserved for small, clinically benign lesions (usually **<1 cm**). Attempting excision on a 1.5 cm lesion in the floor of the mouth without a diagnosis may lead to inadequate margins or unnecessary morbidity. * **Punch Biopsy (Incorrect):** While useful for skin or certain fixed oral sites (like the hard palate), it is less ideal for the mobile, soft tissue of the floor of the mouth where depth control and representative sampling are better achieved via a scalpel incisional biopsy. * **Brush Biopsy (Incorrect):** This is a cytological screening tool, not a diagnostic biopsy. It cannot differentiate between invasive carcinoma and carcinoma in situ. **High-Yield Clinical Pearls for NEET-PG:** * **Size Rule:** Lesion 1 cm → Incisional. * **Location:** The floor of the mouth and the ventrolateral tongue are the most common sites for oral squamous cell carcinoma (SCC). * **Technique:** When performing an incisional biopsy, always include a sample of the **junction between the lesion and normal-appearing tissue** to help the pathologist assess invasion.

Q: A 70-year-old male presented with an asymptomatic white patch on the oral cavity following the application of a denture. What is the treatment of choice?

Ascertaining the denture is fitting completely. **Explanation:** The clinical presentation describes a classic case of **Frictional Keratosis**, a reactive white patch caused by chronic mechanical irritation—in this case, an ill-fitting denture. **1. Why Option C is Correct:** The primary management of any white patch in the oral cavity is to identify and eliminate the inciting factor. Frictional keratosis is a benign hyperkeratotic response to trauma. By **ascertaining the denture fit** and adjusting it, the source of irritation is removed. If the lesion is indeed frictional, it should resolve or significantly improve within 2–3 weeks after the adjustment. **2. Why Other Options are Incorrect:** * **Option A (Radiotherapy):** Radiotherapy is never used for benign reactive lesions or undiagnosed white patches. It is reserved for confirmed malignancies. * **Option B (Biopsy of all tissues):** While biopsy is the gold standard for diagnosing Leukoplakia (a premalignant condition), the first step for a lesion with a clear mechanical cause (denture) is to remove the cause. A biopsy is only indicated if the lesion persists after the irritant is removed. * **Option D (Antibiotics):** White patches (keratosis) represent epithelial thickening, not an acute bacterial infection. Antibiotics have no role in management. **Clinical Pearls for NEET-PG:** * **Rule of Thumb:** Any oral white patch that does not rub off is "Leukoplakia" by clinical definition, but if a cause (like a sharp tooth or denture) is present, it is "Frictional Keratosis." * **The 2-Week Rule:** If a lesion persists 14 days after removing the suspected irritant, a **biopsy** (usually incisional) is mandatory to rule out dysplasia or squamous cell carcinoma. * **Homogeneous vs. Non-homogeneous:** Homogeneous leukoplakia has a lower malignant transformation rate compared to speckled (erythroleukoplakia) or nodular variants.

Q: Which of the following structures is preserved in a functional radical dissection of the neck, except?

Lymph nodes. In neck dissection terminology, the goal of the surgery determines which structures are removed. The primary objective of any neck dissection for malignancy is the systematic removal of **lymph nodes**. ### 1. Why "Lymph Nodes" is the Correct Answer A **Functional Radical Neck Dissection (FRND)**, also known as a Modified Radical Neck Dissection (MRND) Type I, II, or III, is defined by the preservation of one or more non-lymphatic structures that are routinely removed in a Classical Radical Neck Dissection (RND). Since the very purpose of the surgery is to treat or prevent nodal metastasis, the **lymph nodes are never preserved**; they are the target tissue. ### 2. Explanation of Incorrect Options (Structures Preserved) In a **Modified/Functional Radical Neck Dissection**, the following three key non-lymphatic structures are intentionally preserved to reduce morbidity: * **Accessory Nerve (CN XI):** Preserved to prevent "Shoulder Syndrome" (shoulder drop and pain due to trapezius paralysis). * **Internal Jugular Vein (IJV):** Preserved to maintain venous drainage and prevent intracranial pressure spikes (especially critical in bilateral cases). * **Sternocleidomastoid Muscle (SCM):** Preserved to maintain neck contour and protect the carotid sheath. ### 3. Clinical Pearls for NEET-PG * **Radical Neck Dissection (RND):** Removes Level I-V lymph nodes + SCM + IJV + Spinal Accessory Nerve. * **MRND Type I:** Preserves Accessory Nerve. * **MRND Type II:** Preserves Accessory Nerve + IJV. * **MRND Type III (Functional):** Preserves all three (Accessory Nerve + IJV + SCM). * **High-Yield Fact:** The most common nerve injured during neck dissection (excluding the accessory nerve) is the **Marginal Mandibular Nerve**, leading to drooping of the corner of the mouth.

Q: A 4-year-old girl presenting with a painless, mobile, cystic swelling in the midline of her neck, located just below the hyoid bone, is scheduled for tonsillectomy. The swelling measures 2x1x1 cm. An ultrasound reveals a thick-walled cystic lesion. What is the recommended management?

Surgical removal. **Explanation:** The clinical presentation of a midline, mobile, cystic swelling below the hyoid bone in a child is classic for a **Thyroglossal Duct Cyst (TGDC)**. This is the most common congenital neck swelling, resulting from a persistent tract along the descent of the thyroid gland from the foramen caecum to its final pre-tracheal position. **1. Why Surgical Removal is Correct:** The definitive management for a TGDC is surgical excision, specifically the **Sistrunk Procedure**. This involves removing the cyst, the entire ductal tract, and the **central portion of the hyoid bone** to minimize the high risk of recurrence (which is ~50% if the hyoid is not removed). Surgery is indicated to prevent recurrent infections, abscess formation, and the rare risk of papillary thyroid carcinoma (1%) later in life. **2. Why Other Options are Incorrect:** * **Antibiotics:** These are only indicated if the cyst is acutely infected (thyroglossal abscess). They do not treat the underlying anatomical defect. * **Percutaneous Aspiration:** This is contraindicated as it carries a high risk of infection and recurrence; it is neither diagnostic nor curative. * **Chest X-ray:** This has no role in the diagnosis of a neck cyst. However, an **Ultrasound of the neck** is mandatory to confirm the presence of a normal thyroid gland in its usual position before surgery. **Clinical Pearls for NEET-PG:** * **Pathognomonic Sign:** The swelling moves upward on **protrusion of the tongue** (due to attachment to the hyoid) and on deglutition. * **Most Common Site:** Subhyoid (as seen in this case). * **Sistrunk Procedure:** The "Gold Standard" treatment. * **Ectopic Thyroid:** Always rule out if the TGDC is the patient's only functioning thyroid tissue before excision.

Q: A 40-year-old patient presents with a swelling on the left lateral aspect of the neck. Examination reveals a painless swelling that moves side-to-side but not up-and-down. There is no history of tuberculosis. Laboratory investigations, including thyroid profile and CBC, are normal. Ultrasound shows a highly vascular hypoechoic mass lesion anterior to the sternocleidomastoid muscle. A CT angiogram was subsequently performed. What is the most likely diagnosis?

Carotid body paraganglioma. ### Explanation The clinical presentation and imaging findings are classic for a **Carotid Body Paraganglioma** (also known as a Chemodectoma). **Why the Correct Answer is Right:** * **Clinical Sign:** The hallmark of this tumor is the **Fontaine Sign**—the mass is mobile horizontally (side-to-side) but fixed vertically because it is tethered to the carotid bifurcation. * **Location:** It typically presents at the level of the hyoid bone, anterior to the sternocleidomastoid muscle, within the carotid triangle. * **Imaging:** Ultrasound shows a **highly vascular**, hypoechoic mass. The gold standard for diagnosis is CT or MR Angiography, which reveals the pathognomonic **"Lyre Sign"**—the splaying of the internal and external carotid arteries at the bifurcation. **Why Incorrect Options are Wrong:** * **Fibromatosis colli:** This is a benign proliferation of the sternocleidomastoid muscle seen in **neonates/infants** (congenital muscular torticollis), not in 40-year-olds. * **Tubercular lymph node:** Usually presents with constitutional symptoms (fever, weight loss), may show central necrosis on imaging, and is not typically hypervascular on angiography. * **Soft tissue sarcoma:** While these can be vascular, they do not specifically splay the carotid bifurcation or demonstrate the specific horizontal-only mobility characteristic of carotid body tumors. **NEET-PG High-Yield Pearls:** 1. **Lyre Sign:** Widening of the carotid bifurcation on angiography. 2. **Salt-and-Pepper Appearance:** Seen on T1-weighted MRI (Salt = hemorrhage/slow flow; Pepper = flow voids of high-velocity vessels). 3. **Shamblin Classification:** Used to grade these tumors based on their involvement/encasement of the carotid arteries. 4. **Origin:** Arises from the **neural crest cells** (chemoreceptors) located at the carotid body.

Q: What is the most common site for carcinoma of the tongue?

Lateral margin. **Explanation:** Carcinoma of the tongue is the most common intraoral cancer, predominantly presenting as **Squamous Cell Carcinoma (SCC)**. **1. Why Lateral Margin is Correct:** The **lateral margin** of the anterior two-thirds (oral tongue) is the most common site, accounting for approximately **75% of cases**. This is attributed to the "pooling effect," where carcinogens in saliva (from tobacco and alcohol) gravitate toward the floor of the mouth and the lateral borders. Chronic irritation from sharp, jagged teeth or ill-fitting dentures also frequently affects this area, acting as a co-factor in carcinogenesis. **2. Analysis of Incorrect Options:** * **Tip of the tongue:** This is a rare site for malignancy. While it is highly mobile, it has less prolonged contact with pooled carcinogens compared to the lateral borders. * **Posterior 1/3 (Base of Tongue):** This area is part of the oropharynx. While tumors here are often more aggressive and diagnosed at a later stage due to rich lymphatic drainage, they are less frequent than lateral margin tumors. These are increasingly associated with **HPV-16**. * **Ventral surface:** While the ventral surface and floor of the mouth are high-risk areas, they are statistically less common primary sites than the lateral margins. **3. NEET-PG High-Yield Pearls:** * **Lymphatic Drainage:** The tip drains to submental nodes; the lateral borders drain to submandibular nodes (Level Ib); the posterior 1/3 drains directly to deep cervical nodes (Jugulodigastric). * **Premalignant Lesions:** Erythroplakia has a much higher transformation rate than Leukoplakia. * **Prognosis:** The most important prognostic factor is the **depth of invasion (DOI)** and the presence of **lymph node metastasis**. * **Field Cancerization:** This concept explains why patients with one oral primary are at high risk for synchronous or metachronous tumors.

Q: Fracture of a mandible with an edentulous jaw is best treated with which of the following?

External fixator. **Explanation:** The management of mandibular fractures in an **edentulous jaw** (a jaw without teeth) presents a unique challenge because the standard method of stabilization—**Intermaxillary Fixation (IMF)**—cannot be performed due to the lack of teeth to anchor the wires. **Why External Fixator is Correct:** In an edentulous patient, an **External Fixator** (such as the Morris biphase splint) is the preferred treatment when open reduction is not feasible. It provides rigid stabilization by placing pins into the bone fragments through the skin, bypassing the need for dental anchorage. This allows for fracture healing while maintaining the vertical dimension of the face. **Analysis of Incorrect Options:** * **Interdental wiring (C) and Intermaxillary elastic traction (D):** These techniques require a sufficient number of stable teeth in both the upper and lower jaws to "tie" the mouth shut and align the fracture. In an edentulous patient, there is no substrate for these wires or elastics to grip. * **Minerva plaster (B):** This is a specialized orthopedic cast used for cervical and upper thoracic spine fractures (extending from the head to the hips). It has no role in the stabilization of mandibular fractures. **Clinical Pearls for NEET-PG:** * **Gunning Splints:** If an edentulous patient has existing dentures, they can be modified (Gunning splints) and wired to the jaw (circum-mandibular wiring) to act as a substitute for teeth during fixation. * **Atrophy:** Edentulous mandibles are often severely atrophic (thin). This makes them prone to "non-union" and increases the risk of further fracture during surgical plating. * **Gold Standard:** While external fixators are a classic answer for exams, **Open Reduction and Internal Fixation (ORIF)** with mini-plates is increasingly used in modern practice if the bone quality allows.

Q: Which teeth are removed first?

First. **Explanation:** In the context of dental extractions, particularly when multiple teeth are being removed in a single quadrant, the sequence of extraction is clinically significant to ensure surgical efficiency and patient comfort. **Why "First" is the correct answer:** The correct sequence for multiple extractions follows the rule of **"Posterior to Anterior."** Therefore, the **First Molar** (or the most posterior tooth intended for extraction) is removed first. * **Medical Concept:** Removing the most posterior teeth first prevents the surgical field from being obscured by hemorrhage from anterior sites. Furthermore, it allows the surgeon to utilize the space and leverage more effectively. If anterior teeth were removed first, the bleeding would drain posteriorly, hindering the visibility required for the more difficult posterior extractions. **Analysis of Incorrect Options:** * **A & B (Least/Maximal):** These terms refer to the quantity or degree of force/difficulty rather than the chronological sequence of extraction. They do not represent standard surgical protocols. * **C (Last):** The anterior teeth (like canines or incisors) are typically removed last in a quadrant sequence because they are easier to access and their sockets do not provide the same level of visibility challenges when bleeding occurs. **Clinical Pearls for NEET-PG:** * **Order of Extraction:** Always extract **Maxillary teeth before Mandibular teeth** (to prevent debris from falling into lower sockets) and **Posterior teeth before Anterior teeth** (to maintain a clear, blood-free field). * **The "Canine" Exception:** The Maxillary Canine is often considered the most difficult tooth to extract due to its long root and the "canine eminence" of the alveolar bone. * **Nerve Involvement:** During the extraction of the lower third molar, the **Lingual Nerve** is the most commonly injured nerve due to its proximity to the medial aspect of the mandible.

Q: What is the most common site of oral leukoplakia?

Cheek mucosa. **Explanation:** **Leukoplakia** is defined by the WHO as "a white patch or plaque that cannot be characterized clinically or pathologically as any other disease." It is a clinical diagnosis of exclusion and is considered a **premalignant lesion** of the oral cavity. **1. Why Cheek Mucosa is Correct:** The **buccal (cheek) mucosa** is the most common site for oral leukoplakia, particularly along the line of occlusion. This is attributed to the high frequency of chronic irritation (frictional trauma from teeth) and the large surface area exposed to tobacco and betel nut products, which are the primary etiological factors. **2. Analysis of Incorrect Options:** * **Angle of mouth (A):** While common in cases of candidal leukoplakia or nutritional deficiencies, it is not the most frequent site overall. * **Soft palate (C):** This is a less common site for leukoplakia but carries a higher risk of malignant transformation compared to the buccal mucosa. * **Gingiva (D):** Though it can occur here (often associated with smokeless tobacco use), it ranks lower in incidence than the buccal mucosa. **3. Clinical Pearls for NEET-PG:** * **Most Common Site:** Buccal mucosa (Cheek). * **Site with Highest Malignant Potential:** Floor of the mouth, followed by the ventrolateral surface of the tongue and the soft palate complex. * **Etiology:** Tobacco (most common), alcohol, chronic irritation, and HPV (strains 16 and 18). * **Histopathology:** Shows hyperkeratosis, acanthosis, and varying degrees of dysplasia. * **Management:** Biopsy is mandatory to rule out malignancy. Small lesions are excised; large lesions require close follow-up or laser ablation.

Question 1

A patient presents with a 1.5 cm fibroma on the floor of the mouth. What type of biopsy is recommended?

Accepted Answer

Incisional biopsy

Answer

Excisional biopsy

Answer

Punch biopsy

Answer

Brush biopsy

Question 2

A 70-year-old male presented with an asymptomatic white patch on the oral cavity following the application of a denture. What is the treatment of choice?

Accepted Answer

Ascertaining the denture is fitting completely

Answer

Low dose radiotherapy

Answer

Biopsy of all the tissues

Answer

Antibiotics

Question 3

Which of the following structures is preserved in a functional radical dissection of the neck, except?

Accepted Answer

Lymph nodes

Answer

Internal jugular vein

Answer

Sternomastoid muscle

Answer

Accessory nerve

Question 4

A 4-year-old girl presenting with a painless, mobile, cystic swelling in the midline of her neck, located just below the hyoid bone, is scheduled for tonsillectomy. The swelling measures 2x1x1 cm. An ultrasound reveals a thick-walled cystic lesion. What is the recommended management?

Accepted Answer

Surgical removal

Answer

Antibiotics

Answer

Percutaneous aspiration

Answer

Chest X-ray

Question 5

A 40-year-old patient presents with a swelling on the left lateral aspect of the neck. Examination reveals a painless swelling that moves side-to-side but not up-and-down. There is no history of tuberculosis. Laboratory investigations, including thyroid profile and CBC, are normal. Ultrasound shows a highly vascular hypoechoic mass lesion anterior to the sternocleidomastoid muscle. A CT angiogram was subsequently performed. What is the most likely diagnosis?

Accepted Answer

Carotid body paraganglioma

Answer

Fibromatosis colli

Answer

Tubercular lymph node

Answer

Soft tissue sarcoma

Question 6

What is the most common site for carcinoma of the tongue?

Accepted Answer

Lateral margin

Answer

Tip of tongue

Answer

Posterior 1/3

Answer

Ventral surface

Question 7

Fracture of a mandible with an edentulous jaw is best treated with which of the following?

Accepted Answer

External fixator

Answer

Minerva plaster

Answer

Interdental wiring

Answer

Intermaxillary elastic traction

Question 8

Which of the following is true about salivary gland tumors?

Accepted Answer

Adenoid cystic carcinoma (ACC) shows perineural spread and requires wide resection.

Answer

Malignant epithelial cell (MEC) tumors show perineural spread and require wide resection.

Answer

Malignant epithelial cell (MEC) tumors are well-encapsulated and do not require surgical excision.

Answer

Adenoid cystic carcinoma (ACC) is well-encapsulated and does not require surgical excision.

Question 9

Which teeth are removed first?

Accepted Answer

First

Answer

Least

Answer

Maximal

Answer

Last

Question 10

What is the most common site of oral leukoplakia?

Accepted Answer

Cheek mucosa

Answer

Angle of mouth

Answer

Soft palate

Answer

Gingiva

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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