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 patient complains of pain and boggy swelling in the frontal region which is warm and tender. He also complains of drowsiness at times. What is the diagnosis?

Pott's puffy tumor. **Pott's puffy tumor** * **Pott's puffy tumor** is characterized by a focal osteomyelitis of the frontal bone, often complicated by a subperiosteal abscess. The description of **pain and boggy swelling in the frontal region, which is warm and tender**, perfectly matches this condition. * The complication of **drowsiness** indicates potential epidural or intracranial extension of the infection, which is a common and severe consequence of Pott's puffy tumor. *Pyogenic granuloma* * A pyogenic granuloma is a **benign vascular lesion** of the skin or mucous membranes. * While it can be warm and tender, it typically presents as an **eruptive, solitary, red papule or nodule** that bleeds easily, and it does not typically cause boggy swelling in the frontal bone or drowsiness. *Orbital cellulitis* * Orbital cellulitis presents with **pain, swelling, redness, and warmth around the eye,** often with proptosis and ophthalmoplegia. * While it is a serious infection, the primary swelling in this case is described in the **frontal region**, not specifically confined to the orbit, and the specific feature of a "boggy" swelling over bone is more indicative of a frontal bone osteomyelitis. *Cavernous sinus thrombosis* * Cavernous sinus thrombosis is characterized by **headache, painful ophthalmoplegia, proptosis, and vision loss**, often with fever and altered mental status. * While **drowsiness** can be a feature, the presentation lacks the prominent **orbital signs** and localizing frontal boggy swelling specific to the described case; instead, it would typically present predominantly with signs related to cranial nerve involvement and venous congestion of the orbit.

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: A localized nodule of squamous cell carcinoma in the vocal cord is best treated by

Laser therapy. ***Laser therapy (Transoral Laser Microsurgery)*** - **CO2 laser excision** is an excellent first-line treatment for localized T1a squamous cell carcinoma of the vocal cord, offering **>90% cure rates**. - Advantages include: **precise tumor removal**, immediate pathological assessment with margin evaluation, **excellent voice preservation**, and shorter treatment duration compared to radiotherapy. - **Transoral laser microsurgery (TLM)** allows for cord-sparing procedures that maintain vocal function while achieving complete oncological resection. *Radiotherapy* - **Important Note:** **Radiotherapy is EQUALLY effective** as laser therapy for early T1 glottic cancer, with comparable **5-year local control rates (>90%)** and voice quality outcomes. - Both laser surgery and radiotherapy are **guideline-recommended first-line treatments** (NCCN, ESMO guidelines). - Choice between the two depends on tumor characteristics (anterior commissure involvement), patient preference, institutional expertise, and functional outcomes. - In examination contexts, laser therapy may be preferred as it provides histopathological confirmation and is often considered more definitive for "localized nodules." *Cryosurgery* - **Cryosurgery** is rarely used for vocal cord lesions due to **unpredictable tissue destruction**, potential for severe **vocal cord scarring**, and inability to obtain tissue for pathological margin assessment. - Not a standard treatment option for laryngeal cancer. *Surgical excision* - This term is ambiguous as **laser excision IS a form of surgical excision**. - If referring to **open surgical approaches** (laryngofissure, cordectomy via external approach), these are more invasive than transoral laser surgery and are reserved for larger tumors or salvage situations. - Traditional "cold steel" endoscopic excision is less precise than laser and can cause more trauma and scarring.

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.

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.

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 patient complains of pain and boggy swelling in the frontal region which is warm and tender. He also complains of drowsiness at times. What is the diagnosis?

Accepted Answer

Pott's puffy tumor

Answer

Pyogenic granuloma

Answer

Orbital cellulitis

Answer

Cavernous sinus thrombosis

Question 3

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 4

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 5

A localized nodule of squamous cell carcinoma in the vocal cord is best treated by

Accepted Answer

Laser therapy

Answer

Cryosurgery

Answer

Radiotherapy

Answer

Surgical excision

Question 6

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 7

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 8

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 9

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

Question 10

Tongue fixation in a patient with carcinoma tongue is staged as

Accepted Answer

T4

Answer

T1

Answer

T2

Answer

T3

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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