Head and Neck Surgery Practice Questions

Q: A 35-year-old lady who presented with a 6-month painless fluctuant, non-transilluminant swelling with a thin watery discharge. Clinical diagnosis is?

TB. ***TB*** - **Tuberculosis (TB)** lymphadenopathy often presents as a **painless, fluctuant, non-transilluminant cervical swelling** (scrofula) with possible **thin, watery discharge** from a sinus tract [1]. - The 6-month duration indicates a **chronic process**, consistent with the indolent nature of TB infection [1]. *Brachial cyst* - A **branchial cleft cyst** typically presents as a **smooth, movable, and sometimes fluctuant neck mass**, but it is usually **transilluminant** unless infected. - While it can discharge, the fluid is often mucoid, and the discharge is less commonly described as thin and watery; also it typically develops during childhood or early adulthood. *Secondaries* - **Metastatic lymph nodes (secondaries)** are generally **firm, non-fluctuant, and non-tender**, and do not typically discharge thin watery fluid unless there is necrosis or ulceration of the overlying skin. - The absence of associated primary malignancy symptoms also makes this less likely. *Lymphoma* - **Lymphoma** presents as often **painless rubbery, firm, and non-fluctuant lymph node enlargement**, and discharge is not a typical feature unless there is skin involvement or ulceration in advanced stages. - The described fluctuance and watery discharge are not characteristic of simple lymphoma.

Q: What is the most likely diagnosis for this 60-year-old man with the lesion shown in the image?

SCC of lip. ***SCC of lip*** - The image displays a **chronic, ulcerated, crusted lesion** on the **lower lip** of an older male, which is highly characteristic of **squamous cell carcinoma (SCC) of the lip**, particularly with a history of sun exposure. - SCC of the lip often affects the lower lip due to greater sun exposure and presents as a **non-healing ulcer** or **crusted lesion** that can be indurated at the base. *Plunging Ranula* - A plunging ranula is typically a **cystic lesion** appearing in the **neck** or **submandibular space**, originating from the **sublingual gland**. - It is a **mucous extravasation cyst** and does not present as an ulcerated, crusted lesion on the lip itself. *Basal cell carcinoma* - While **basal cell carcinoma (BCC)** can occur on the face, it is **rare on the lip mucosa** and typically presents as a **pearly nodule with telangiectasias**, often with rolled borders. - The lesion in the image appears more infiltrative and ulcerative than a typical BCC, and its location on the lip with sun exposure points more towards SCC. *Epulis* - An **epulis** is a **gingival growth** or **tumor-like lesion** that arises from the gum tissue, typically caused by chronic irritation or inflammation. - It is usually a **benign, localized fibrous or granulomatous lesion** and does not present as a malignant ulceration on the lip like the one shown.

Q: Investigations used for CSF rhinorrhea are all except:

Skull X-ray. ***Skull X-ray*** - A **skull X-ray** is generally not useful for diagnosing **CSF rhinorrhea** as it lacks the detailed soft tissue resolution needed to identify CSF leaks. - It cannot visualize small defects in the skull base or detect the presence of CSF distinct from other nasal secretions. *CT cisternogram* - A **CT cisternogram** is a highly effective imaging modality for localizing **CSF leaks**, involving an intrathecal injection of contrast followed by CT scanning. - It can pinpoint the exact site of the leak in the skull base, which is crucial for surgical planning. *Beta-2 transferrin* - **Beta-2 transferrin** is a protein found almost exclusively in **cerebrospinal fluid (CSF)**, making its detection in nasal discharge diagnostic of CSF rhinorrhea. - This biochemical test offers high specificity for confirming the presence of CSF. *Nasal endoscopy* - **Nasal endoscopy** allows direct visualization of the nasal cavity and can help identify the source of the leak, especially if active dripping is observed. - During the procedure, the Valsalva maneuver or changes in head position can sometimes provoke or increase the flow of CSF, aiding in localization.

Q: A 46-year-old patient develops a verrucous carcinoma in the oral cavity. What is true of this lesion?

It is most commonly found on the inside of the cheek.. ***It is most commonly found on the inside of the cheek.*** - **Verrucous carcinoma** often presents in the **buccal mucosa** (inside of the cheek) and gingiva as a slow-growing, warty lesion. - This specific location is a common site for the development of such lesions due to chronic irritation or tobacco use. *It is best treated with radiation.* - **Verrucous carcinoma** is primarily treated with **surgical excision** due to its expansive, non-metastatic growth and the risk of anaplastic transformation with radiation therapy. - **Radiation therapy** is generally avoided as it can potentially induce a more aggressive, conventional squamous cell carcinoma within the verrucous lesion. *It is associated with a high metastatic rate.* - **Verrucous carcinoma** is characterized by its **exophytic, non-invasive growth** and has a very **low metastatic potential**, distinguishing it from conventional squamous cell carcinoma. - While locally destructive, its tendency to metastasize is an exceptional occurrence, making it a generally less aggressive malignancy in terms of distant spread. *It is ulcerating in appearance.* - **Verrucous carcinoma** typically presents as a **warty, pebble-like, or cauliflower-like lesion** with a white or grayish surface, rather than an ulcerating one. - **Ulceration** is more characteristic of conventional squamous cell carcinoma, which has a more aggressive infiltrative growth pattern.

Q: While shaving, a 45-year-old teacher notices a marble-sized mass beneath his left ear. The mass is eventually excised, revealing which of the following benign parotid gland lesions?

Warthin tumor. ***Warthin tumor*** - **Warthin tumors** are benign, cystic tumors of the parotid gland, often presenting as a painless, soft, and mobile mass, consistent with a "marble-sized mass." - They are the second most common benign parotid neoplasm and are frequently found in older men, especially those who smoke. *Cystic dilation* - While cystic dilation can occur in the parotid gland, it is typically associated with conditions like **sialolithiasis** (salivary stones) or ductal obstruction, which would usually present with pain and swelling secondary to eating. - The description of a "marble-sized mass" without other symptoms is less typical for simple cystic dilation. *Mikulicz's disease* - Mikulicz's disease, or **IgG4-related sclerosing disease**, is a systemic condition characterized by chronic inflammation and fibrosis of exocrine glands, leading to bilateral, diffuse enlargement of various glands, including the parotid. - It usually presents with diffuse, persistent swelling, not a solitary, marble-sized mass, and is associated with elevated IgG4 levels. *Glandular hypertrophy, secondary to vitamin A deficiency* - **Glandular hypertrophy** of the parotid gland can occur due to various systemic conditions, but it is typically a diffuse, bilateral enlargement, not a discrete, unilateral mass. - While vitamin A deficiency can lead to metaplasia of glandular epithelium, it is not a direct cause of parotid gland hypertrophy or discrete mass formation.

Q: Best method to evaluate bone defect is

Sounding. ***Sounding*** - **Sounding** involves inserting a periodontal probe into the bone defect to measure its depth and morphology, providing a direct and accurate assessment. - This method is particularly useful for evaluating the **clinical attachment loss** and the configuration of intrabony defects. *Use of Florida probe* - The **Florida probe** is a computerized periodontal probe used for precise measurement of probing depths and clinical attachment levels. - While accurate for soft tissue measurements, it does not directly assess bone defects or their morphology. *Bitewing radiograph* - **Bitewing radiographs** are primarily used to detect interproximal caries and assess the alveolar bone level. - They provide a two-dimensional image and are not ideal for evaluating the three-dimensional morphology or true depth of bone defects. *IOPA* - **Intraoral periapical (IOPA) radiographs** show the entire tooth, including the apex and surrounding bone. - While they can reveal some bony changes, they offer a two-dimensional view and may underestimate the extent of bone loss, especially around the roots, due to superimposition.

Q: Which cancer has maximum propensity to spread to cervical lymph nodes?

Nasopharyngeal carcinoma. ***Nasopharyngeal carcinoma*** - This cancer is notorious for presenting with **cervical lymph node metastasis** in over 80% of patients, often as the first clinical sign, due to the rich lymphatic drainage of the nasopharynx. - Its hidden location deep within the head makes early detection difficult, leading to diagnosis at a later stage when regional spread has already occurred. *Carcinoma of soft palate* - While it can metastasize to cervical nodes, especially levels II and III, its propensity is generally lower than nasopharyngeal carcinoma. - The lymphatic drainage is more localized compared to the extensive network of the nasopharynx. *Carcinoma of hard palate* - This cancer has a relatively **low rate of regional nodal metastasis**, typically ranging from 10-20%. - Lymphatic drainage is primarily to submandibular and jugulodigastric nodes, but less aggressively than other head and neck cancers. *Carcinoma of mandible* - Mandibular cancers, especially those involving the oral mucosa, can metastasize to cervical lymph nodes (e.g., submental, submandibular, jugulodigastric). - However, the overall frequency and extent of cervical lymph node involvement are less pronounced compared to nasopharyngeal carcinoma.

Q: Carcinoma tongue less than 2 cm is treated by -

Excision. ***Excision*** - **Early-stage oral tongue carcinoma** (T1, less than 2 cm) is primarily treated with **surgical excision** due to its high cure rates. - The goal is complete removal with **clear margins**, which is often curative for small lesions. *Excision and Radiotherapy* - While excision is appropriate, **adjuvant radiotherapy** is typically reserved for larger tumors, those with **positive margins**, **lymph node involvement**, or **perineural/vascular invasion**. - For very small tumors (<2 cm) with clear margins and no high-risk features, radiotherapy is often **overtreatment** and adds unnecessary side effects. *Chemotherapy* - **Chemotherapy** is generally used in more advanced stages of oral tongue carcinoma, either as neoadjuvant therapy, concurrent with radiotherapy, or for metastatic disease. - It is **not a primary treatment** for early-stage localized disease due to its systemic toxicity and limited role in local control compared to surgery. *Radiotherapy* - **Radiotherapy alone** can be used as a primary treatment for oral tongue carcinoma, especially in patients who are **unfit for surgery** or refuse surgery. - However, for small lesions, **surgery typically offers better local control** and avoids the long-term side effects of radiation, such as xerostomia and osteoradionecrosis.

Q: Which of the following is false about parotid tumor

Malignant disease is most common variety. ***Malignant disease is most common variety*** - This statement is false because the vast majority (approximately 80%) of **parotid gland tumors** are **benign**, with **pleomorphic adenoma** being the most common type. - Only about 20% of parotid tumors are **malignant**, making them a less common variety than benign tumors. *Facial nerve involvement indicates malignancy* - **Facial nerve palsy** or weakness in the presence of a parotid mass is a significant red flag and a strong indicator of **malignancy** within the parotid gland. - Malignant tumors can **infiltrate** and damage the facial nerve, leading to its dysfunction. *Pleomorphic adenoma is most common* - **Pleomorphic adenoma**, also known as mixed tumor, is indeed the **most common benign tumor** of the parotid gland, accounting for the large majority of all parotid neoplasms. - It typically presents as a slow-growing, painless mass. *Superficial parotidectomy is the treatment* - For tumors confined to the **superficial lobe** of the parotid gland (where most parotid tumors are located), a **superficial parotidectomy** is the standard surgical treatment. - This procedure removes the superficial lobe while preserving the **facial nerve**, which runs within the gland.

Q: N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:

Metastasis in a lymph node >6 cm. ***Metastasis in a lymph node >6 cm*** - **N3a disease** in head and neck cancer staging (AJCC 8th edition) specifically refers to metastasis in a single lymph node larger than 6 cm in greatest dimension **without extranodal extension (ENE)**. - This applies to oral cavity, oropharynx (HPV-negative), hypopharynx, and larynx cancers. - **Note:** N3 staging also includes **N3b** (metastasis in any node with clinically overt ENE), but this question specifically asks about N3a criteria. *Metastasis in lymph nodes >2 cm* - Lymph nodes in the 2-3 cm range typically fall within **N1 or N2a categories**, depending on laterality and number of involved nodes. - **N3a disease** requires a single lymph node to exceed 6 cm in greatest dimension without ENE. *Metastasis in lymph nodes >5 cm* - A lymph node between 3-6 cm is usually classified as **N2 disease** (N2a if single ipsilateral ≤6 cm, N2b if multiple ipsilateral ≤6 cm, N2c if bilateral or contralateral ≤6 cm). - To be classified as **N3a**, the lymph node must be **>6 cm** without extranodal extension. *None of the options* - This option is incorrect because the first option accurately describes the size criterion for **N3a TNM staging** in head and neck tumors according to AJCC 8th edition guidelines. - While N3 staging has two subcategories (N3a and N3b), the size criterion of >6 cm correctly defines N3a disease.

Question 1

A 35-year-old lady who presented with a 6-month painless fluctuant, non-transilluminant swelling with a thin watery discharge. Clinical diagnosis is?

Accepted Answer

TB

Answer

Brachial cyst

Answer

Secondaries

Answer

Lymphoma

Question 2

What is the most likely diagnosis for this 60-year-old man with the lesion shown in the image?

Accepted Answer

SCC of lip

Answer

Plunging Ranula

Answer

Basal cell carcinoma

Answer

Epulis

Question 3

Investigations used for CSF rhinorrhea are all except:

Accepted Answer

Skull X-ray

Answer

CT cisternogram

Answer

Beta-2 transferrin

Answer

Nasal endoscopy

Question 4

A 46-year-old patient develops a verrucous carcinoma in the oral cavity. What is true of this lesion?

Accepted Answer

It is most commonly found on the inside of the cheek.

Answer

It is best treated with radiation.

Answer

It is associated with a high metastatic rate.

Answer

It is ulcerating in appearance.

Question 5

While shaving, a 45-year-old teacher notices a marble-sized mass beneath his left ear. The mass is eventually excised, revealing which of the following benign parotid gland lesions?

Accepted Answer

Warthin tumor

Answer

Cystic dilation

Answer

Mikulicz's disease

Answer

Glandular hypertrophy, secondary to vitamin A deficiency

Question 6

Best method to evaluate bone defect is

Accepted Answer

Sounding

Answer

Use of Florida probe

Answer

Bitewing radiograph

Answer

IOPA

Question 7

Which cancer has maximum propensity to spread to cervical lymph nodes?

Accepted Answer

Nasopharyngeal carcinoma

Answer

Carcinoma of soft palate

Answer

Carcinoma of hard palate

Answer

Carcinoma of mandible

Question 8

Carcinoma tongue less than 2 cm is treated by -

Accepted Answer

Excision

Answer

Excision and Radiotherapy

Answer

Chemotherapy

Answer

Radiotherapy

Question 9

Which of the following is false about parotid tumor

Accepted Answer

Malignant disease is most common variety

Answer

Facial nerve involvement indicates malignancy

Answer

Pleomorphic adenoma is most common

Answer

Superficial parotidectomy is the treatment

Question 10

N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:

Accepted Answer

Metastasis in a lymph node >6 cm

Answer

Metastasis in lymph nodes >2 cm

Answer

Metastasis in lymph nodes >5 cm

Answer

None of the options

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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