Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 21: Which structure is damaged in a high tracheostomy?

A. Thyroid isthmus
B. Aortic knuckle
C. First tracheal ring (Correct Answer)
D. Recurrent laryngeal nerve

Explanation: **Explanation:** In surgical practice, tracheostomy is categorized based on its relationship to the **thyroid isthmus**, which typically overlies the 2nd, 3rd, and 4th tracheal rings. 1. **Why Option C is Correct:** A **high tracheostomy** is performed above the level of the thyroid isthmus, specifically involving the **1st tracheal ring**. This procedure is strictly contraindicated in elective cases because damage to the 1st tracheal ring or the cricoid cartilage can lead to **perichondritis** and subsequent **subglottic stenosis**, a debilitating long-term complication. 2. **Why other options are incorrect:** * **Thyroid isthmus (A):** This is the landmark used to define the level. In a mid-tracheostomy (the preferred elective site), the isthmus is either retracted or divided to access the 2nd and 3rd rings. * **Aortic knuckle (B):** This is a mediastinal structure located far inferior to the tracheostomy site. It is only at risk in "low tracheostomies" (below the 4th ring) in patients with a high-riding innominate artery or in children. * **Recurrent laryngeal nerve (D):** These nerves run in the tracheoesophageal groove. While they can be injured during lateral dissection, they are not the primary structure damaged by the "high" placement of the tracheal opening itself. **Clinical Pearls for NEET-PG:** * **Ideal Site:** The 2nd and 3rd tracheal rings (Mid-tracheostomy) are the safest for elective procedures. * **Emergency Airway:** If an immediate airway is needed and a standard tracheostomy is too slow, **Cricothyroidotomy** is the procedure of choice. * **Most Common Complication:** Immediate (Hemorrhage); Late (Tracheal stenosis).

Question 22: Facial nerve injury occurs during parotid surgery. What is the best management?

A. Immediate repair (Correct Answer)
B. Repair at a later date
C. Physiotherapy
D. No intervention

Explanation: **Explanation:** The management of facial nerve injury during parotidectomy depends on whether the injury was **recognized intraoperatively** or **postoperatively**. **1. Why Immediate Repair is Correct:** If the facial nerve is accidentally transected during surgery, **immediate primary repair** (neurorrhaphy) is the gold standard. * **Anatomical Alignment:** The nerve ends are fresh and easily identifiable within the surgical field before scarring or fibrosis occurs. * **Better Outcomes:** Immediate microsurgical end-to-end anastomosis (or a cable graft using the great auricular or sural nerve if there is tension) provides the best functional recovery. * **Wallerian Degeneration:** Repairing the nerve before the distal segment undergoes significant degeneration preserves the motor endplates more effectively. **2. Why Other Options are Incorrect:** * **Repair at a later date:** Delayed repair is significantly more difficult due to the formation of dense scar tissue and the difficulty in locating the retracted distal nerve branches. It is usually reserved for cases where the wound is heavily contaminated or the patient is unstable. * **Physiotherapy:** While helpful for muscle toning during recovery, it cannot restore nerve continuity. It is an adjunct, not a primary treatment for transection. * **No intervention:** This leads to permanent facial paralysis (Bell's palsy-like appearance), muscle atrophy, and corneal ulceration due to inability to close the eye. **Clinical Pearls for NEET-PG:** * **Most common nerve injured** in parotid surgery: Facial nerve (specifically the marginal mandibular branch). * **Most common site of injury:** At the exit from the stylomastoid foramen or as it bifurcates at the *pes anserinus*. * **Post-operative paralysis:** If paralysis is noted immediately after the patient wakes up (and was not recognized during surgery), it often indicates transection and requires re-exploration. If it develops hours later, it is likely due to edema or neuropraxia and is managed conservatively.

Question 23: What is the name of the incision shown below?

A. Lazy 'S' incision
B. Weber-Ferguson incision (Correct Answer)
C. Sistrunk incision
D. Modified Blair's

Explanation: ***Weber-Ferguson incision*** - A **lip-split incision** that extends from the **philtrum** through the **alar base** and along the **infraorbital rim**, providing excellent exposure for **maxillectomy** procedures. - Specifically designed for **total maxillectomy** and **rhinectomy**, allowing wide access to the **maxillary sinus** and **nasal cavity** while maintaining good cosmetic outcomes. *Lazy 'S' incision* - A **parotidectomy incision** that follows a curved **S-shaped** path from the **preauricular** area to the **neck**, used specifically for **parotid gland** surgery. - Does not involve **lip-splitting** or **facial extension** like the Weber-Ferguson, making it unsuitable for **maxillary** procedures. *Sistrunk incision* - A **horizontal neck incision** used specifically for **thyroglossal duct cyst** excision, located over the **hyoid bone** level. - Does not provide any **facial** or **maxillary** access, being limited to **central neck** pathology only. *Modified Blair's* - A **parotidectomy incision** that extends from the **preauricular** area around the **ear lobule** into the **neck**, used for **parotid gland** procedures. - Like the Lazy S, it's designed for **parotid surgery** and does not involve **midface** or **maxillary** exposure.

Question 24: A 21-year-old woman presents with a 3 cm node in the lower deep cervical chain on the left. Biopsy reveals normal thyroid tissue within a lymph node. What is the most likely diagnosis?

A. Subacute thyroiditis
B. Papillary carcinoma of the thyroid (Correct Answer)
C. Hashimoto's disease
D. Lateral aberrant thyroid

Explanation: **Explanation:** The presence of "normal-looking" thyroid tissue within a cervical lymph node is a classic presentation of metastatic **Papillary Carcinoma of the Thyroid (PTC)**. This phenomenon occurs because PTC is a highly lymphophilic tumor that frequently spreads to regional lymph nodes. Even when the metastatic deposits appear histologically well-differentiated (resembling normal follicles), they are pathologically considered metastatic cancer. **Why the other options are incorrect:** * **Lateral Aberrant Thyroid:** This was an older anatomical theory suggesting that thyroid tissue could develop independently in the lateral neck. Modern embryology and pathology have debunked this; any thyroid tissue found lateral to the internal jugular vein or within a lymph node is considered metastatic PTC until proven otherwise. * **Subacute Thyroiditis & Hashimoto’s Disease:** These are inflammatory/autoimmune conditions of the thyroid gland. While they may cause reactive lymphadenopathy, they do not cause the migration of thyroid follicular cells into the lymphatic system. **NEET-PG High-Yield Pearls:** * **Orphan Annie Eye Nuclei:** The pathognomonic histological feature of PTC (large, pale, clear nuclei). * **Psammoma Bodies:** Laminated calcifications often seen in PTC. * **Route of Spread:** PTC spreads primarily via **lymphatics** (unlike Follicular Carcinoma, which spreads hematogenously). * **Prognosis:** Despite early lymphatic spread (even in young patients), PTC has an excellent long-term prognosis. * **Rule of Thumb:** Any thyroid tissue found in a cervical lymph node is **metastatic papillary carcinoma** until proven otherwise.

Question 25: A female presented with a severe headache of sudden onset. On CT scan, a diagnosis of subarachnoid hemorrhage is made. What is the most common cause of subarachnoid hemorrhage?

A. Middle meningeal artery
B. Berry aneurysm rupture (Correct Answer)
C. Basilar artery
D. Subdural venous sinuses

Explanation: **Explanation:** **Subarachnoid Hemorrhage (SAH)** is characterized by bleeding into the subarachnoid space, typically presenting as a "thunderclap headache" (the worst headache of one's life). 1. **Why Berry Aneurysm is Correct:** The most common cause of **spontaneous (non-traumatic)** SAH is the rupture of a **Berry (saccular) aneurysm**, accounting for approximately 80% of cases. These aneurysms typically occur at the bifurcations of arteries within the Circle of Willis, most commonly at the junction of the **Anterior Communicating Artery**. 2. **Why Other Options are Incorrect:** * **Middle Meningeal Artery:** Rupture of this artery (usually due to trauma at the pterion) leads to an **Epidural Hematoma (EDH)**, characterized by a biconvex/lens-shaped bleed on CT and a classic "lucid interval." * **Basilar Artery:** While aneurysms can occur here, they are far less common than those in the anterior circulation. * **Subdural Venous Sinuses:** Tearing of the bridging veins (which drain into these sinuses) results in a **Subdural Hematoma (SDH)**, typically seen as a crescent-shaped bleed on CT in elderly or alcoholic patients. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA) is the gold standard for identifying the site of the aneurysm. * **Initial Investigation:** Non-contrast CT (NCCT) Head (shows hyperdensity in cisterns and sulci). * **Associated Conditions:** Berry aneurysms are associated with **ADPKD**, Ehlers-Danlos syndrome, and Coarctation of the Aorta. * **Complication:** Vasospasm is a major delayed complication (3–14 days); **Nimodipine** (a calcium channel blocker) is used to improve outcomes.

Question 26: What is true about carotid body tumors?

A. Arises from Schwann cells
B. Causes hypertension
C. Arises from endothelial cells
D. None of the above (Correct Answer)

Explanation: **Explanation:** Carotid body tumors (CBTs), also known as **chemodectomas** or **paragangliomas**, are rare neoplasms arising from the **extra-adrenal neural crest cells** (specifically the chief cells) located at the bifurcation of the common carotid artery. **Why Option D is Correct:** None of the provided descriptions accurately define the origin or typical clinical presentation of a carotid body tumor. **Analysis of Incorrect Options:** * **Option A:** CBTs do not arise from Schwann cells. Tumors arising from Schwann cells are called **Schwannomas** or Neurilemmomas. CBTs arise from **Type I Chief cells** of the paraganglia. * **Option B:** Unlike adrenal pheochromocytomas, carotid body tumors are usually **non-functional**. They rarely secrete catecholamines (<5% of cases); therefore, they do not typically cause hypertension. * **Option C:** CBTs do not arise from endothelial cells. Tumors of endothelial origin include hemangiomas or angiosarcomas. **High-Yield Clinical Pearls for NEET-PG:** * **Fontaine’s Sign:** The tumor is vertically fixed but **horizontally mobile** because it is located within the carotid sheath. * **Lyre Sign:** On angiography, the tumor causes characteristic **widening/splaying** of the carotid bifurcation (displacement of internal and external carotid arteries). * **Shamblin Classification:** Used to grade the tumor based on its involvement/encasement of the carotid vessels (Group I to III). * **Histology:** Features a characteristic **"Zellballen" pattern** (clusters of chief cells surrounded by sustentacular cells and vascular stroma). * **Rule of 10s:** Approximately 10% are bilateral, 10% are familial, and 10% are malignant.

Question 27: A 58-year-old woman undergoes excision biopsy of a tumor in the left posterior triangle of her neck. Histology suggests that this is a metastatic cancer. What is the most likely site of the primary tumor?

A. Ovary
B. Adrenal gland
C. Kidney
D. Piriform fossa (Correct Answer)

Explanation: **Explanation:** The clinical presentation of a metastatic lymph node in the **posterior triangle** (Level V) of the neck in an adult most commonly points to a primary malignancy within the **Upper Aerodigestive Tract (UADT)**. **1. Why Piriform Fossa is Correct:** The piriform fossa is a part of the hypopharynx. Tumors in this region are notorious for being "clinically silent" in their early stages while having a rich lymphatic network. Consequently, they often present first as a metastatic neck mass. While Level II and III nodes are more common, hypopharyngeal and nasopharyngeal carcinomas are the most frequent primary sources for metastases found in the **posterior triangle (Level V)**. **2. Why Incorrect Options are Wrong:** * **Ovary, Adrenal Gland, and Kidney:** These are infraclavicular (below the diaphragm) organs. While they can metastasize to the neck, they typically involve the **Supraclavicular nodes** (specifically the left supraclavicular node, known as **Virchow’s node** or Troisier’s sign) via the thoracic duct. They do not typically present as isolated posterior triangle masses. **3. NEET-PG High-Yield Pearls:** * **Rule of 80:** In a non-thyroid neck mass in an adult, 80% are neoplastic; of those, 80% are malignant; of those, 80% are metastatic; and of those, 80% arise from primaries above the clavicle. * **Levels of Neck Nodes:** * **Level V (Posterior Triangle):** Think Nasopharynx, Hypopharynx, or Scalp. * **Level II (Upper Jugular):** Think Oral cavity, Oropharynx. * **Silent Areas:** Always check the "blind spots" (Nasopharynx, Tonsil, Base of tongue, and Piriform fossa) in any case of occult primary neck metastasis.

Question 28: 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?

A. Low dose radiotherapy
B. Biopsy of all the tissues
C. Ascertaining the denture is fitting completely (Correct Answer)
D. Antibiotics

Explanation: **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.

Question 29: Which of the following structures is preserved in a functional radical dissection of the neck, except?

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

Explanation: 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.

Question 30: 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?

A. Surgical removal (Correct Answer)
B. Antibiotics
C. Percutaneous aspiration
D. Chest X-ray

Explanation: **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.

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

Practice Questions

Surgical Approaches to the Neck

Practice Questions

Neck Dissection Techniques

Practice Questions

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