Head and Neck Surgery Practice Questions

Q: A gentleman of 60 years presented with a brawny swelling of the submandibular region with inflammatory edema of mouth and putrid halitosis. Most likely he is suffering from

Ludwig's angina. ***Ludwig's angina*** - This is a **rapidly progressive cellulitis** of the submandibular, sublingual, and submental spaces, commonly originating from **odontogenic infections**. - The classic presentation includes **brawny edema** (firm, woody induration) of the submandibular region, inflammatory edema of the mouth, and **putrid halitosis** indicative of an anaerobic infection. *Acute lymphadenitis* - This involves inflammation of the lymph nodes, typically characterized by **tender, enlarged nodes**. - While it can be associated with infection, it usually does not present with the diffuse, *brawny* swelling of the floor of the mouth and submandibular area as described, nor the severe systemic symptoms often linked to Ludwig's angina. *Tubercular adenitis* - This is a **chronic granulomatous inflammation** of lymph nodes, typically presenting as slowly enlarging, **non-tender masses**. - It does not cause acute, rapidly spreading cellulitis or *brawny* edema with severe halitosis, which are hallmark features of Ludwig's angina. *Chronic lymphadenitis* - This refers to persistent or recurrent inflammation of lymph nodes, often due to protracted infection or inflammatory processes. - It usually manifests as **enlarged, firm, sometimes mobile lymph nodes**, but does not involve the acute, diffuse, and rapidly spreading *brawny* edema characteristic of a severe fascial space infection like Ludwig's angina.

Q: Tongue fixation in a patient with carcinoma tongue is staged as

T4. ***T4*** - **Tongue fixation** in carcinoma of the tongue indicates advanced local disease classified as **T4a stage** according to AJCC TNM staging. - This finding suggests invasion of **extrinsic tongue muscles**, which causes loss of tongue mobility and represents moderately advanced local disease. - T4a tumors invade through cortical bone, involve the inferior alveolar nerve, floor of mouth, or skin of face, or in the case of tongue, involve deep extrinsic muscles causing fixation. *T1* - **T1 tumors** are small lesions measuring **≤2 cm** in greatest dimension with **depth of invasion (DOI) ≤5 mm**. - They are superficial without invasion of deep structures or causing any functional impairment like tongue fixation. *T2* - **T2 tumors** measure **≤2 cm with DOI >5 mm and ≤10 mm**, OR **>2 cm but ≤4 cm with DOI ≤10 mm**. - While larger than T1, they do not involve deep extrinsic muscles or cause tongue fixation. *T3* - **T3 tumors** are defined as tumors **>4 cm** OR **any tumor with DOI >10 mm**. - Although T3 indicates larger tumor size and deeper invasion, **tongue fixation** specifically indicates T4a stage due to involvement of extrinsic tongue musculature.

Q: Which one of the following structures is not removed during a classical radical neck dissection?

Trapezius. ***Trapezius*** - The **trapezius muscle** is consistently spared (not removed) in a classical radical neck dissection, although it becomes non-functional due to sacrifice of its motor nerve supply. - While the muscle remains anatomically in place, removal of the **accessory nerve** leads to denervation of the trapezius, causing severe shoulder dysfunction including **shoulder drop** and inability to abduct the arm past 90 degrees. *Accessory nerve* - The **accessory nerve (cranial nerve XI)** is sacrificed in a classical radical neck dissection to ensure complete removal of lymphatic tissue and metastatic disease. - Its removal results in **denervation and paralysis of the trapezius muscle**, leading to shoulder weakness, shoulder drop, and limited shoulder abduction. - The accessory nerve also innervates the sternocleidomastoid, though this muscle is removed in the procedure. *Sternocleidomastoid* - The **sternocleidomastoid muscle** is removed in a classical radical neck dissection for oncological clearance, as lymph nodes closely associated with it can harbor metastatic disease. - Its removal contributes to cosmetic defect and can affect neck contour and mobility. *Internal jugular vein* - The **internal jugular vein** is resected during a classical radical neck dissection to achieve en bloc removal of lymphatic tissue in levels II, III, and IV, which often contain metastatic disease. - Its removal can lead to **venous congestion** in the head and neck initially, although collateral circulation through the external jugular and vertebral venous systems usually develops over time.

Q: A patient operated for a parotid gland tumour developed symptoms of sweating and erythema (flushing) over the region of surgical excision while eating. The probable diagnosis is:

Frey's syndrome. ***Frey's syndrome*** - **Frey's syndrome**, also known as auriculotemporal syndrome, is characterized by gustatory sweating and flushing in the preauricular or temporal region during mastication (eating). - This occurs due to aberrant regeneration of damaged postganglionic parasympathetic fibers that previously supplied the parotid gland. These fibers mistakenly reinnervate sweat glands and blood vessels in the skin, leading to sweating and flushing when salivary stimulation occurs. *Sialadenitis* - **Sialadenitis** is inflammation of a salivary gland, typically presenting with pain, swelling, and sometimes fever, and is not directly linked to sweating while eating. - It is usually caused by infection or obstruction, and its symptoms would not be localized to the surgical excision site with flushing and sweating upon eating. *Parotid gland fistula* - A **parotid gland fistula** involves the leakage of saliva through an opening in the skin, which would manifest as continuous or intermittent salivary drainage, not sweating and flushing. - This condition is a direct communication between the parotid duct or gland parenchyma and the skin surface. *Chronic wound infection* - A **chronic wound infection** would present with persistent pain, redness, warmth, swelling, and possibly purulent discharge at the surgical site. - Sweating and flushing specifically triggered by eating are not characteristic symptoms of a wound infection.

Q: Which of these is the STRONGEST indication for giving adjuvant treatment in oral malignancy after resection and Modified Radical Neck Dissection (MRND)?

Extranodal extension. ***Extranodal extension*** - **Extranodal extension (ENE)** is the strongest adverse pathological feature (APF) indicating the highest risk of recurrence and significantly impacting prognosis. - ENE is associated with increased likelihood of regional and distant metastasis. - The presence of ENE mandates **adjuvant concurrent chemoradiotherapy** (not radiotherapy alone), as landmark trials (EORTC 22931, RTOG 9501) demonstrated survival benefit with combined modality treatment. - ENE and positive surgical margins are the two most critical features requiring intensified adjuvant therapy. *Multiple lymph node metastasis* - Multiple positive lymph nodes (≥2 nodes) indicate high risk of recurrence and warrant **adjuvant radiotherapy**. - While this is a significant adverse feature, it does not mandate chemoradiotherapy unless accompanied by ENE or positive margins. - Considered a high-risk feature but not as strong an indication as ENE. *T3 tumor* - T3 tumor indicates significant local invasion but is a clinical staging parameter, not a pathological adverse feature. - The decision for adjuvant therapy depends primarily on pathological findings (margins, lymph node status, ENE) rather than T-stage alone. - T3 status without adverse pathological features may not require adjuvant treatment after complete resection. *Close margin* - Close margin (tumor within 1-5 mm of resected edge) is a high-risk feature warranting **adjuvant radiotherapy** due to increased local recurrence risk. - However, it is less critical than ENE in terms of overall survival and regional control. - A **positive margin** (<1 mm or tumor at ink) would be equivalent to ENE as an indication for chemoradiotherapy, but a close margin typically requires radiotherapy alone.

Q: Which nerve is most commonly injured during submandibular gland surgery?

Marginal mandibular branch of facial nerve. ***Marginal mandibular branch of facial nerve*** - The **marginal mandibular nerve** courses superficially over and along the superior border of the submandibular gland, making it the **most vulnerable** structure during surgery - It is at highest risk during elevation of the gland, ligation of the facial vessels, and dissection near the gland's superior border - Injury leads to **weakness or paralysis of the depressor muscles of the lower lip** (depressor anguli oris and depressor labii inferioris), causing an asymmetric smile and difficulty with lip movements - This is the **most common nerve injury** in submandibular gland surgery due to its superficial anatomical position *Incorrect: Lingual nerve* - The **lingual nerve** passes medial to the submandibular duct and deep to the gland - While it can be injured during dissection of the submandibular duct or deeper aspects of the gland, it is **less commonly injured** than the marginal mandibular nerve - Damage results in **loss of taste and general sensation** to the anterior two-thirds of the tongue on the ipsilateral side *Incorrect: Mylohyoid nerve* - The **mylohyoid nerve** travels on the inferior surface of the mylohyoid muscle, generally beneath and protected by this muscle - It supplies the mylohyoid and anterior belly of the digastric muscles - Injury is **uncommon** during routine submandibular gland excision due to its protected anatomical position *Incorrect: Hypoglossal nerve* - The **hypoglossal nerve** lies deep and inferior to the submandibular gland - It supplies motor innervation to the intrinsic and extrinsic muscles of the tongue - It is the **least commonly injured** nerve as it is well-protected by its deep position, unless dissection is carried excessively deep or inferiorly

Q: A 35-year-old male presents with posterior epistaxis. Conservative management including nasal packing to stop the bleeding was unsuccessful. What is the next step in the management of this patient?

Endoscopic sphenopalatine artery ligation. ***Endoscopic sphenopalatine artery ligation*** - **Sphenopalatine artery ligation** is the most common surgical intervention for **posterior epistaxis** that is refractory to conservative management (e.g., nasal packing). - It is highly effective because the sphenopalatine artery is the major blood supply to the **posterior nasal cavity**. *Internal carotid artery (ICA) ligation* - **ICA ligation** is rarely performed for epistaxis due to the risk of **neurological complications**, such as stroke. - The ICA primarily supplies the brain, and its contribution to nasal bleeding is indirect and not typically the primary source. *Maxillary artery ligation* - The **maxillary artery** is the parent artery of the sphenopalatine artery, but ligating it more proximally carries a higher risk of complications and is less precise. - Due to the deep anatomical location, this approach is more invasive and technically challenging than sphenopalatine artery ligation. *External carotid artery (ECA) ligation* - **ECA ligation** is a more proximal and less selective procedure than sphenopalatine artery ligation, meaning other vessels may be ligated unnecessarily. - While it can reduce blood flow, it may not be as effective as direct sphenopalatine artery ligation for controlling severe posterior epistaxis, as collateral blood flow can still occur.

Q: What is the likely diagnosis of the image given below?

Ranula. ***Ranula*** - The image exhibits a characteristic **translucent, bluish, dome-shaped swelling** on the floor of the mouth, which is highly suggestive of a ranula. - A ranula is a type of **mucocele specifically involving the sublingual gland** or minor salivary glands in the floor of the mouth, often due to obstruction or trauma to the salivary duct. *Dermoid cyst* - While dermoid cysts can appear on the floor of the mouth, they typically present as a **firmer, doughy consistency** and are often **yellowish or skin-colored**, due to their epithelial and adnexal contents. - They are usually located in the midline and are **congenital lesions**, which differ in appearance from the fluid-filled, translucent nature of a ranula. *Mucocele* - A mucocele is a general term for a mucus retention cyst, but they typically present as **smaller, painless, bluish, benign lesions** found on the **lips** (especially the lower lip) or buccal mucosa, resulting from trauma to minor salivary glands. - The size and specific location (floor of the mouth associated with sublingual gland) in the image point more specifically to a ranula rather than a general mucocele. *Ludwig angina* - Ludwig angina is a **severe, rapidly spreading cellulitis of the submandibular and sublingual spaces**, usually stemming from an odontogenic infection. - It presents with **firm, brawny swelling of the submandibular region** and floor of the mouth, often accompanied by fever, dysphagia, and airway compromise, which are not depicted in the image.

Q: What is the most likely diagnosis for the swelling in the floor of the mouth shown in the image?

Ranula. ***Ranula*** - The image shows a **translucent, bluish, dome-shaped swelling** in the **floor of the mouth**, consistent with a ranula. - A ranula is a **mucus extravasation cyst** caused by trauma or obstruction of the **sublingual salivary gland** duct, leading to mucus accumulation. *Dermoid* - A **dermoid cyst** in the floor of the mouth typically presents as a **firm, doughy, non-translucent swelling**, often located in the midline. - Unlike a ranula, dermoid cysts are usually **not bluish** and contain **ectodermal elements** like hair and sebaceous material. *Branchial cyst* - **Branchial cysts** are congenital abnormalities typically found in the **lateral neck**, anterior to the sternocleidomastoid muscle. - They are generally **not found in the floor of the mouth** and arise from remnants of the branchial arches. *Cystic hygroma* - A **cystic hygroma** is a **lymphatic malformation**, commonly appearing as a soft, compressible, transilluminable mass, predominantly in the **neck** and axilla. - While it can be large and cystic, its typical location and presentation are **different from a floor of mouth swelling** like a ranula.

Question 1

A gentleman of 60 years presented with a brawny swelling of the submandibular region with inflammatory edema of mouth and putrid halitosis. Most likely he is suffering from

Accepted Answer

Ludwig's angina

Answer

Acute lymphadenitis

Answer

Tubercular adenitis

Answer

Chronic lymphadenitis

Question 2

Tongue fixation in a patient with carcinoma tongue is staged as

Accepted Answer

T4

Answer

T1

Answer

T2

Answer

T3

Question 3

Which one of the following structures is not removed during a classical radical neck dissection?

Accepted Answer

Trapezius

Answer

Accessory nerve

Answer

Sternocleidomastoid

Answer

Internal jugular vein

Question 4

A patient operated for a parotid gland tumour developed symptoms of sweating and erythema (flushing) over the region of surgical excision while eating. The probable diagnosis is:

Accepted Answer

Frey's syndrome

Answer

Sialadenitis

Answer

Parotid gland fistula

Answer

Chronic wound infection

Question 5

An elderly patient presents with a non-healing ulcerative lesion on the lower lip, as shown in the image. The lesion has been gradually enlarging over the past few months. Suspecting squamous cell carcinoma (SCC), what is the most appropriate method to obtain a biopsy for definitive diagnosis?

Accepted Answer

Incisional

Answer

Excisional

Answer

Deep tissue biopsy

Answer

Superficial biopsy from the border with normal tissue

Question 6

Which of these is the STRONGEST indication for giving adjuvant treatment in oral malignancy after resection and Modified Radical Neck Dissection (MRND)?

Accepted Answer

Extranodal extension

Answer

Multiple lymph node metastasis

Answer

T3 tumor

Answer

Close margin

Question 7

Which nerve is most commonly injured during submandibular gland surgery?

Accepted Answer

Marginal mandibular branch of facial nerve

Answer

Lingual nerve

Answer

Mylohyoid nerve

Answer

Hypoglossal nerve

Question 8

A 35-year-old male presents with posterior epistaxis. Conservative management including nasal packing to stop the bleeding was unsuccessful. What is the next step in the management of this patient?

Accepted Answer

Endoscopic sphenopalatine artery ligation

Answer

Internal carotid artery (ICA) ligation

Answer

Maxillary artery ligation

Answer

External carotid artery (ECA) ligation

Question 9

What is the likely diagnosis of the image given below?

Accepted Answer

Ranula

Answer

Dermoid cyst

Answer

Mucocele

Answer

Ludwig angina

Question 10

What is the most likely diagnosis for the swelling in the floor of the mouth shown in the image?

Accepted Answer

Ranula

Answer

Dermoid

Answer

Branchial cyst

Answer

Cystic hygroma

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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