Head and Neck Surgery Practice Questions

Q: A 45-year-old patient presents with a slowly progressive, painless swelling in the parotid region as shown in the image. The mass is firm, non-tender, and freely mobile. Identify the most likely diagnosis.

Pleomorphic adenoma. ***Pleomorphic adenoma*** - The clinical presentation of a **solitary, well-circumscribed, slowly growing, painless mass** in the parotid gland region with **free mobility** is highly characteristic of **pleomorphic adenoma**, the most common benign salivary gland tumor (constitutes 60-70% of parotid tumors). - It typically occurs in the 4th-5th decade, grows slowly over months to years, and is **firm but not fixed** to surrounding structures. - The image shows a **unilateral, localized swelling** in the pre-auricular region without acute inflammatory signs, consistent with this diagnosis. *Mumps* - Mumps is an **acute viral infection (paramyxovirus)** causing **bilateral, painful swelling of the parotid glands**, often accompanied by fever, malaise, and orchitis. - The image depicts a **unilateral, localized, chronic swelling** without signs of acute inflammation, unlike the acute, diffuse, tender bilateral swelling typical of mumps. - Mumps rarely presents as a solitary unilateral mass in adults. *Retro-auricular lymphadenopathy* - **Retro-auricular lymphadenopathy** presents as discrete, movable lymph nodes located **posterior to the ear**, often in response to scalp or ear infections. - The lesion shown is a **larger, more diffuse swelling located anterior to the ear** in the parotid region, inconsistent with isolated lymph node enlargement. - Lymph nodes are typically smaller, multiple, and more mobile than the mass shown. *Sialadenitis* - **Acute sialadenitis** is an **inflammatory/infectious condition** of salivary glands presenting with **acute onset pain, tenderness, erythema, warmth**, and sometimes purulent discharge from the duct. - The lesion appears as a **chronic, painless, solid mass** lacking acute inflammatory signs (significant erythema, warmth, tenderness, purulent discharge). - Chronic sialadenitis would show recurrent episodes of painful swelling, which is not suggested by the clinical presentation.

Q: A 35-year-old HIV+ patient presents with the following lesion in the neck. What is correct about the management?

Gravity drainage + ATT. ***Gravity drainage + ATT*** - The image shows a **scrofula**, presenting as an abscess in the cervical lymph nodes, likely due to **tuberculous lymphadenitis**. In such cases, **gravity drainage** is crucial to evacuate the purulent material effectively, especially in the neck region. - **Anti-tubercular therapy (ATT)** is the mainstay for treating tuberculosis, and it must be initiated in combination with drainage to eradicate the infection. *ATT for another 6 months* - While ATT is essential, it is **insufficient as a standalone treatment** for a mature draining abscess like the one depicted. - Simply continuing ATT without addressing the localized collection of pus would likely result in delayed healing and potential complications. *Anti-gravity drainage + ATT* - **Anti-gravity drainage** is generally not feasible or effective for abscesses in the neck, as gravity aids in the natural flow of exudates. - This approach would go against the principles of surgical drainage for fluid collections. *Incision and drainage* - While **incision and drainage (I&D)** is a standard procedure for many abscesses, caution is exercised in tuberculous lymphadenitis (scrofula) due to the risk of creating a **continuous fistula** or **non-healing sinus**. - **Repeat aspirations** or **gravity drainage** with concurrent ATT are preferred over formal incision and drainage to minimize scarring and fistula formation.

Q: A 40-year-old smoker presents with soreness of tongue since last 2 months. On examination, it is found that the oral hygiene is poor and there is a white plaque over the lateral border of the tongue. What is the next step in the management of this patient?

Edge biopsy of the lesion. ***Edge biopsy of the lesion*** - The patient's presentation with a **white plaque** on the lateral border of the tongue, coupled with **poor oral hygiene** and a history of **smoking**, raises high suspicion for **oral potentially malignant disorders**, including **leukoplakia** or early **squamous cell carcinoma**. - An **edge biopsy** is the most appropriate next step to obtain a definitive histological diagnosis, which is crucial for determining the correct management strategy and ruling out malignancy. - The lateral border of the tongue is a **high-risk site** for oral cancer, and any persistent lesion in a smoker warrants tissue diagnosis. *Oral antifungal treatment* - This would be indicated if the white plaque were consistent with **oral candidiasis (thrush)**, which typically presents as **scrapable** white patches with a cottage cheese-like appearance. - Given the patient's significant risk factors (smoking, 2-month duration) and the location (lateral tongue border), empirical antifungal treatment without a definitive diagnosis would inappropriately delay management if the lesion is precancerous or cancerous. *Local topical cauterization* - **Cauterization** is contraindicated for undiagnosed oral lesions, especially those suspected of having malignant potential, as it could obscure the true histology and destroy tissue needed for diagnosis. - This method is only suitable for small, confirmed benign lesions or for hemostasis, never as a diagnostic or first-line approach. *Oral vitamin C supplementation* - While **vitamin C** supports overall health and tissue repair, there is no evidence it would resolve a suspicious white plaque on the tongue, especially one with potential malignant transformation. - Delaying proper diagnostic evaluation with supplementation alone could lead to progression of a serious underlying condition such as oral cancer.

Q: The commonest site for thyroglossal cyst is :

Subhyoid. ***Subhyoid (Infrahyoid)*** - The **subhyoid (infrahyoid) region** is the most common location for thyroglossal cysts, accounting for **50-65% of cases**. - The thyroglossal duct passes through or is intimately related to the **body of the hyoid bone** during embryonic descent of the thyroid gland from the foramen cecum [1], [2]. - Cysts most frequently form **at or just below the level of the hyoid bone** in the midline neck. - These cysts characteristically **move upward with swallowing and tongue protrusion** due to their attachment to the hyoid bone. *Suprahyoid* - Suprahyoid cysts occur **above the hyoid bone** and account for approximately **20-25% of cases**. - While common, they are **less frequent than subhyoid cysts**. - These may present higher in the neck but still maintain the characteristic midline location. *Submentum* - The submental region is **anterior and superior to the hyoid bone** in the midline. - Thyroglossal cysts in this location are **uncommon** as the duct's path runs more posteriorly in relation to this space. - True submental cysts are rare and must be differentiated from dermoid cysts. *Foramen caecum* - This is the **embryological origin** of the thyroglossal duct at the base of the tongue [1], [2]. - Cysts at this location are called **lingual thyroglossal cysts** and are very rare (1-2% of cases) [1]. - They present as tongue base masses and can cause dysphagia or airway obstruction.

Q: The structures removed in radical neck dissection include: 1. Sternocleidomastoid muscle 2. Submandibular gland 3. Internal jugular vein 4. Accessory nerve

1, 2, 3 and 4. ***1, 2, 3 and 4*** - A **radical neck dissection** involves the removal of the **sternocleidomastoid muscle**, **internal jugular vein**, and **spinal accessory nerve (cranial nerve XI)**, along with all cervical lymph node groups from levels I to V, and the submandibular gland. - This extensive procedure is designed to achieve complete tumor clearance, particularly in cases of advanced head and neck cancers with suspected or confirmed nodal metastases. *1 and 2 only* - This option is incomplete as a radical neck dissection targets more structures than just the **sternocleidomastoid muscle** and **submandibular gland**. - While these two structures are removed, the procedure also extensively addresses major neurovascular structures and lymph nodes to ensure comprehensive cancer eradication. *1 and 3 only* - This option is incomplete because a radical neck dissection also involves the removal of the **submandibular gland** and the **accessory nerve**, in addition to the sternocleidomastoid muscle and internal jugular vein. - The goal is to clear all potential pathways of cancer spread in the neck. *2 and 4 only* - This option is incorrect as it omits other key structures removed in a radical neck dissection, such as the **sternocleidomastoid muscle** and the **internal jugular vein**. - These structures are critical components of the surgical field to adequately remove all affected tissues.

Q: Consider the following statements : Branchial cysts : 1. are associated with tracks passing between the carotid bifurcation. 2. usually present in early adulthood. 3. occur along the lower one-third of the anterior border of the sternocleidomastoid muscle. 4. develop from the vestigial remnants of the fourth branchial cleft. Which of the statements given above are correct?

1, 2 and 3 only. ***1, 2 and 3 only*** - **Branchial cysts** (specifically **second branchial cleft cysts**) are frequently associated with a **sinus tract** that passes between the **internal and external carotid arteries** (carotid bifurcation) and opens into the tonsillar fossa. - They commonly present in **late childhood or early adulthood** as a slowly enlarging, painless mass, often located along the **anterior border of the sternocleidomastoid muscle**, typically at the junction of the upper two-thirds and lower one-third of the neck. *2, 3 and 4 only* - This option incorrectly states that branchial cysts develop from the **fourth branchial cleft**. Most common branchial cysts are derived from the **second branchial cleft** (accounting for >90% of cases). - While statements 2 and 3 are correct regarding presentation and location, the origin from the fourth branchial cleft is generally not applicable to the most prevalent type of branchial cyst. *1, 2, 3 and 4* - This option includes the incorrect statement that branchial cysts typically originate from the **fourth branchial cleft**. The vast majority (over 90-95%) of branchial cleft anomalies arise from the **second branchial cleft**. - While all other statements (1, 2, and 3) are characteristic of second branchial cleft cysts, the inclusion of the fourth branchial cleft origin makes this option incorrect. *1 and 2 only* - This option correctly identifies the association with tracks passing through the carotid bifurcation and presentation in early adulthood. - However, it omits the correct statement that branchial cysts typically occur along the **lower one-third of the anterior border of the sternocleidomastoid muscle**, which is a key anatomical location and an important clinical finding for diagnosis.

Q: With reference to Le Fort I fracture, consider the following statements : 1. Fracture line separates alveolus and palate from the facial skeleton. 2. Fracture line passes from the pyriform aperture. 3. Fracture line runs posteriorly to include pterygoid plates. 4. Fracture line passes through orbit. Which of the statements given above are correct?

1, 2 and 3. ***Correct Answer: 1, 2 and 3*** - A **Le Fort I fracture** (floating palate fracture) involves a horizontal fracture line separating the **maxillary alveolus and hard palate** from the rest of the facial skeleton, confirming statement 1. - The fracture path includes the **pyriform aperture** anteriorly (statement 2) and extends posteriorly to involve the **pterygoid plates of the sphenoid bone** (statement 3). - Statement 4 is **incorrect** because Le Fort I fractures do **not** involve the orbit; this is a low-level fracture below the orbital floor. *Incorrect: 1 and 2 only* - This option is incomplete as it omits statement 3, which is a defining characteristic of Le Fort I fractures. - The fracture **must** extend posteriorly to include the **pterygoid plates** to be classified as a Le Fort I. *Incorrect: 2, 3 and 4* - Statement 4 is incorrect for a Le Fort I fracture. - Le Fort I fractures are located **inferiorly** and do **not** involve the orbital floor or walls. - Orbital involvement is characteristic of **Le Fort II** (pyramidal fracture) or **Le Fort III** (craniofacial dysjunction) fractures. *Incorrect: 1 and 3 only* - This option omits statement 2, which accurately describes the involvement of the **pyriform aperture** in Le Fort I fractures. - The fracture line **consistently** passes through the pyriform aperture anteriorly as it traverses the lower maxilla.

Q: In a lateral facial wound, if facial nerve injury is suspected, it should be:

Primary repair should be attempted. ***Primary repair should be attempted*** - **Early surgical repair** of facial nerve injuries, ideally within the first 72 hours, offers the best chance for **functional recovery**. - **Primary repair** involves direct reapproximation and meticulous suturing of the severed nerve ends under magnification. *Left alone* - Leaving a suspected facial nerve injury untreated can lead to **permanent facial paralysis** and significant functional and aesthetic deficits. - The facial nerve has a limited capacity for spontaneous regeneration, especially after a **complete transection**. *Secondary repair using microscope gives best result* - While microscopic techniques are crucial for nerve repair, **secondary repair** (performed weeks or months after the injury) generally yields poorer outcomes compared to primary repair. - **Scar tissue formation** and **nerve end retraction** make secondary repair more challenging and less effective. *Skin and subcutaneous flaps to be raised to cover the cut ends* - This approach addresses wound closure but **does not repair the underlying nerve injury**, leading to persistent motor deficits. - Covering the nerve ends without repair would still result in **facial paralysis** as the nerve fibers cannot reconnect across the gap.

Q: A 70 year old male having comorbidities presents with benign appearing parotid tumour. The best option is:

Superficial Parotidectomy. ***Superficial Parotidectomy*** - This is the **standard surgical treatment** for benign parotid tumors, even in elderly patients with comorbidities, as it offers the best balance of **low recurrence risk** and **preservation of facial nerve function**. - The procedure removes the superficial lobe of the parotid gland, where most benign tumors are located, and allows for **intraoperative facial nerve monitoring**. *Tumour enucleation* - This procedure has a **higher risk of tumor recurrence** as it does not remove a cuff of healthy tissue around the tumor. - It also has a greater chance of **facial nerve injury** due to the lack of clear dissection planes. *Radio therapy* - Radiotherapy is generally reserved for **malignant parotid tumors** or as an adjuvant therapy after incomplete resection of high-grade malignancies. - It carries risks of **xerostomia**, radiation-induced fibrosis, and potential secondary malignancies, making it less suitable for benign conditions. *Aspiration biopsy confirmation* - While an aspiration biopsy (Fine Needle Aspiration Cytology, FNAC) is crucial for **preoperative diagnosis**, it is not a treatment option. - It helps in planning the definitive surgical approach but does not address the tumor itself.

Question 1

A 45-year-old patient presents with a slowly progressive, painless swelling in the parotid region as shown in the image. The mass is firm, non-tender, and freely mobile. Identify the most likely diagnosis.

Accepted Answer

Pleomorphic adenoma

Answer

Mumps

Answer

Retro-auricular lymphadenopathy

Answer

Sialadenitis

Question 2

A 35-year-old HIV+ patient presents with the following lesion in the neck. What is correct about the management?

Accepted Answer

Gravity drainage + ATT

Answer

ATT for another 6 months

Answer

Anti-gravity drainage + ATT

Answer

Incision and drainage

Question 3

A 40-year-old smoker presents with soreness of tongue since last 2 months. On examination, it is found that the oral hygiene is poor and there is a white plaque over the lateral border of the tongue. What is the next step in the management of this patient?

Accepted Answer

Edge biopsy of the lesion

Answer

Oral antifungal treatment

Answer

Local topical cauterization

Answer

Oral vitamin C supplementation

Question 4

The commonest site for thyroglossal cyst is :

Accepted Answer

Subhyoid

Answer

Submentum

Answer

Suprahyoid

Answer

Foramen caecum

Question 5

The structures removed in radical neck dissection include:

1. Sternocleidomastoid muscle
2. Submandibular gland
3. Internal jugular vein
4. Accessory nerve

Accepted Answer

1, 2, 3 and 4

Answer

1 and 2 only

Answer

1 and 3 only

Answer

2 and 4 only

Question 6

Consider the following statements :

Branchial cysts :

1. are associated with tracks passing between the carotid bifurcation.
2. usually present in early adulthood.
3. occur along the lower one-third of the anterior border of the sternocleidomastoid muscle.
4. develop from the vestigial remnants of the fourth branchial cleft.

Which of the statements given above are correct?

Accepted Answer

1, 2 and 3 only

Answer

2, 3 and 4 only

Answer

1, 2, 3 and 4

Answer

1 and 2 only

Question 7

With reference to Le Fort I fracture, consider the following statements :

1. Fracture line separates alveolus and palate from the facial skeleton.

2. Fracture line passes from the pyriform aperture.

3. Fracture line runs posteriorly to include pterygoid plates.

4. Fracture line passes through orbit.
Which of the statements given above are correct?

Accepted Answer

1, 2 and 3

Answer

1 and 2 only

Answer

2, 3 and 4

Answer

1 and 3 only

Question 8

A 50 year old man with long history of swelling in his right parotid region had sudden history of occasional pain, nerve weakness along with paresthesia. His fine needle aspiration cytology was inconclusive. What should be the next step?

Accepted Answer

MRI

Answer

CT Scan

Answer

Trucut Biopsy

Answer

Superficial Parotidectomy

Question 9

In a lateral facial wound, if facial nerve injury is suspected, it should be:

Accepted Answer

Primary repair should be attempted

Answer

Left alone

Answer

Secondary repair using microscope gives best result

Answer

Skin and subcutaneous flaps to be raised to cover the cut ends

Question 10

A 70 year old male having comorbidities presents with benign appearing parotid tumour. The best option is:

Accepted Answer

Superficial Parotidectomy

Answer

Tumour enucleation

Answer

Radio therapy

Answer

Aspiration biopsy confirmation

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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