Head and Neck Surgery — MCQs

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?

Q315

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

Q316

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?

Q317

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?

Q318

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

Q319

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

Q320

Tongue fixation in a patient with carcinoma tongue is staged as

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 311: 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.

A. Pleomorphic adenoma (Correct Answer)
B. Mumps
C. Retro-auricular lymphadenopathy
D. Sialadenitis

Explanation: ***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.

Question 312: 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?

A. Pyogenic granuloma
B. Orbital cellulitis
C. Cavernous sinus thrombosis
D. Pott's puffy tumor (Correct Answer)

Explanation: **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.

Question 313: The structures removed in radical neck dissection include: 1. Sternocleidomastoid muscle 2. Submandibular gland 3. Internal jugular vein 4. Accessory nerve

A. 1 and 2 only
B. 1 and 3 only
C. 2 and 4 only
D. 1, 2, 3 and 4 (Correct Answer)

Explanation: ***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.

Question 314: 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?

A. 2, 3 and 4 only
B. 1, 2, 3 and 4
C. 1, 2 and 3 only (Correct Answer)
D. 1 and 2 only

Explanation: ***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.

Question 315: A localized nodule of squamous cell carcinoma in the vocal cord is best treated by

A. Cryosurgery
B. Radiotherapy
C. Laser therapy (Correct Answer)
D. Surgical excision

Explanation: ***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.

Question 316: 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?

A. 1 and 2 only
B. 2, 3 and 4
C. 1 and 3 only
D. 1, 2 and 3 (Correct Answer)

Explanation: ***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.

Question 317: 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?

A. CT Scan
B. Trucut Biopsy
C. Superficial Parotidectomy
D. MRI (Correct Answer)

Explanation: MRI - **MRI** is the preferred imaging modality for **parotid lesions** as it provides superior soft tissue contrast and can better delineate tumor extent, perineural invasion, and involvement of adjacent structures. The new onset of pain, nerve weakness, and paresthesia suggests a potentially aggressive tumor or **malignant transformation**, making precise imaging crucial. [1] - An **MRI** can help differentiate between benign and malignant lesions based on signal characteristics and can guide further management including surgical planning or the need for a more invasive biopsy. *CT Scan* - While a **CT scan** can provide good bony detail and may show larger lesions, it offers less soft tissue resolution compared to MRI, making it less ideal for detailed evaluation of parotid pathologies, especially for assessing **nerve involvement** and **perineural invasion**. - A **CT scan** involves **ionizing radiation**, and given the need for detailed soft tissue assessment in this scenario, **MRI** is generally preferred for salivary gland imaging. *Trucut Biopsy* - A **Trucut biopsy** is a more invasive procedure that is not the appropriate next step after an inconclusive FNA. Given the new neurological symptoms suggesting possible malignancy, **comprehensive imaging with MRI is essential first** to characterize the lesion, assess extent, evaluate for perineural invasion, and understand the relationship to critical structures like the facial nerve. - Performing another biopsy before adequate imaging could delay appropriate management and does not provide the anatomical information needed for surgical planning. If imaging suggests malignancy, either imaging-guided biopsy or proceeding directly to surgery may be more appropriate depending on the clinical scenario. *Superficial Parotidectomy* - **Superficial parotidectomy** is a surgical procedure for tumor removal and is definitive treatment, but it is not the next step after an inconclusive **FNA** and new symptoms suggestive of malignancy without clear imaging. - Surgery without adequate preoperative imaging and potentially a definitive diagnosis (or strong suspicion of malignancy from imaging) is premature and could lead to incomplete resection or unnecessary intervention. **MRI is essential for surgical planning** to assess tumor extent and plan the appropriate procedure (superficial vs total parotidectomy) [2].

Question 318: In a lateral facial wound, if facial nerve injury is suspected, it should be:

A. Left alone
B. Secondary repair using microscope gives best result
C. Skin and subcutaneous flaps to be raised to cover the cut ends
D. Primary repair should be attempted (Correct Answer)

Explanation: ***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.

Question 319: A 70 year old male having comorbidities presents with benign appearing parotid tumour. The best option is:

A. Tumour enucleation
B. Radio therapy
C. Aspiration biopsy confirmation
D. Superficial Parotidectomy (Correct Answer)

Explanation: ***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 320: Tongue fixation in a patient with carcinoma tongue is staged as

A. T1
B. T2
C. T3
D. T4 (Correct Answer)

Explanation: ***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.

Practice by Chapter

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