Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 321: Which one of the following structures is not removed during a classical radical neck dissection?

A. Trapezius (Correct Answer)
B. Accessory nerve
C. Sternocleidomastoid
D. Internal jugular vein

Explanation: ***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.

Question 322: 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:

A. Sialadenitis
B. Parotid gland fistula
C. Frey's syndrome (Correct Answer)
D. Chronic wound infection

Explanation: ***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.

Question 323: Which of the following procedures would be difficult to perform based on the given Chest X-ray?

A. Tracheostomy (Correct Answer)
B. Laryngeal mask airway insertion
C. Ryle's tube insertion
D. Intubation

Explanation: ***Tracheostomy*** - The chest X-ray shows the presence of a **large thyroid mass** (appearing as a soft tissue density in the neck and upper mediastinum), which would displace the trachea and obscure anatomical landmarks, making a tracheostomy technically challenging and increasing the risk of complications. - A tracheostomy requires clear access to the anterior tracheal wall, which would be **directly obstructed** by the prominent thyroid hypertrophy visible on the X-ray. - This makes tracheostomy the **most difficult** procedure among the options, with significant risk of bleeding from engorged thyroid vessels and difficulty identifying the trachea. *Laryngeal mask airway insertion* - Laryngeal mask airway (LMA) insertion primarily involves placing a device over the **laryngeal inlet** and is not significantly affected by a mass lower in the neck impacting the trachea. - The LMA is a supraglottic device, and its placement does not require direct access to the trachea itself or the deeper structures of the neck. *Ryle's tube insertion* - Ryle's tube (nasogastric tube) insertion involves passing a tube from the **nose or mouth into the esophagus and stomach**. - This procedure is generally unaffected by a thyroid mass, as it primarily involves the gastrointestinal tract, which is anatomically separate from the trachea in the neck region. *Intubation* - Intubation (endotracheal intubation) involves placing a tube into the **trachea via the mouth or nose**, usually past the vocal cords. - While a large retrosternal thyroid mass can cause tracheal deviation and compression that may complicate intubation, it is generally **less difficult than tracheostomy** in this scenario. - Intubation can often be achieved with experienced anesthesia techniques (videolaryngoscopy, fiberoptic intubation), whereas tracheostomy faces direct surgical field obstruction by the thyroid mass itself. - The primary challenge for intubation is visualization and navigation past the vocal cords, not the direct anatomical obstruction at the surgical site that makes tracheostomy particularly difficult.

Question 324: 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?

A. Incisional (Correct Answer)
B. Excisional
C. Deep tissue biopsy
D. Superficial biopsy from the border with normal tissue

Explanation: ***Incisional*** - An **incisional biopsy** is the most appropriate method for obtaining a definitive diagnosis of suspected squamous cell carcinoma (SCC) of the lip. - This technique involves removing a **wedge-shaped portion of the lesion** that includes both the tumor tissue and a margin extending into normal tissue, with adequate depth to assess invasion. - Incisional biopsy provides sufficient tissue for **histopathological examination**, including assessment of tumor grade, depth of invasion, and other prognostic factors critical for staging and treatment planning. - For larger or suspicious lesions where complete excision might cause significant cosmetic deformity, incisional biopsy allows for **diagnosis confirmation before definitive surgical management**. *Superficial biopsy from the border with normal tissue* - A superficial or shave biopsy is **inadequate for SCC diagnosis** as it does not provide information about the depth of invasion, which is crucial for staging and prognosis. - Squamous cell carcinoma requires assessment of invasion into underlying dermis and deeper structures, which cannot be evaluated with superficial sampling. - Superficial biopsies may lead to **underdiagnosis** or incomplete staging, potentially compromising treatment planning. *Excisional* - While excisional biopsy (complete removal with margins) can be appropriate for **small, well-defined lesions** (<1 cm), it may not be the first choice for larger or gradually enlarging lesions. - Complete excision without prior histological confirmation might result in **inadequate margins** if malignancy is confirmed, requiring re-excision. - For lip lesions, unnecessary wide excision can cause **significant cosmetic and functional defects** if the lesion proves benign or requires specialized reconstruction. *Deep tissue biopsy* - This is not standard terminology in the context of lip lesions and lacks specificity regarding the sampling technique. - The term "deep tissue biopsy" is more commonly used for suspected soft tissue tumors or deep-seated lesions, not for mucocutaneous SCC.

Question 325: Which of these is the STRONGEST indication for giving adjuvant treatment in oral malignancy after resection and Modified Radical Neck Dissection (MRND)?

A. Extranodal extension (Correct Answer)
B. Multiple lymph node metastasis
C. T3 tumor
D. Close margin

Explanation: ***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.

Question 326: Which nerve is most commonly injured during submandibular gland surgery?

A. Lingual nerve
B. Marginal mandibular branch of facial nerve (Correct Answer)
C. Mylohyoid nerve
D. Hypoglossal nerve

Explanation: ***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

Question 327: 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?

A. Internal carotid artery (ICA) ligation
B. Maxillary artery ligation
C. External carotid artery (ECA) ligation
D. Endoscopic sphenopalatine artery ligation (Correct Answer)

Explanation: ***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.

Question 328: What is the most likely diagnosis for the swelling in the floor of the mouth shown in the image?

A. Dermoid
B. Ranula (Correct Answer)
C. Branchial cyst
D. Cystic hygroma

Explanation: ***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 329: A 12-year-old presented with fever and difficulty swallowing. He had swelling in the marked region and was advised to undergo tonsillectomy. Post-surgery the gauze continued to soak with blood. Which of the following vessels must have been injured?

A. Ascending pharyngeal artery
B. Tonsillar branch of facial artery
C. Retromandibular vein
D. Paratonsillar vein (Correct Answer)

Explanation: ***Paratonsillar vein*** - The **paratonsillar vein**, also known as the **external palatine vein**, is the major vein draining the palatine tonsil and usually the primary source of **post-tonsillectomy hemorrhage**. - Its superficial location and tendency to be large and thin-walled make it particularly vulnerable to injury during **tonsillectomy**, leading to persistent bleeding. *Ascending pharyngeal artery* - The ascending pharyngeal artery contributes to the blood supply of the tonsil, but it is a **deep-seated artery** that is less frequently injured during tonsillectomy compared to the paratonsillar vein. - While its injury could lead to significant bleeding, it's not the most common vascular source of hemorrhage in this context. *Tonsillar branch of facial artery* - The **tonsillar branch of the facial artery** is a significant arterial supply to the tonsil. However, arterial bleeding is typically more pulsatile and rapid, whereas persistent soaking of gauze suggests venous bleeding. - While injury to this artery can occur, the **paratonsillar vein** is a more common source of persistent oozing hemorrhage post-tonsillectomy. *Retromandibular vein* - The **retromandibular vein** is located posterior to the mandible and is not directly associated with the tonsillar bed. - Injury to this vein during a **tonsillectomy** is highly unlikely due to its anatomical position.

Question 330: Which among the following is not used in post laryngectomy rehabilitation?

A. Tracheostomy tube (Correct Answer)
B. Esophageal speech
C. Tracheoesophageal puncture
D. Electrolarynx

Explanation: ***Tracheostomy tube*** - Following total laryngectomy, the **trachea is permanently diverted** to form a permanent stoma in the neck for breathing. - In the context of **post-laryngectomy rehabilitation**, the focus is on **voice restoration** methods rather than airway management devices. - While laryngectomy tubes or stoma buttons may be used temporarily for **stoma care** (preventing stenosis, maintaining patency), traditional **tracheostomy tubes are not part of voice rehabilitation** protocols. - The patient breathes directly through the permanent stoma, and rehabilitation centers on restoring communication ability. *Esophageal speech* - **Esophageal speech** is a voice rehabilitation method where air is injected into the esophagus and then expelled, vibrating the pharyngoesophageal segment to produce sound. - It requires no external devices, only extensive training, and can provide functional voice for communication. - This is one of the **three main voice restoration options** after laryngectomy. *Tracheoesophageal puncture* - **Tracheoesophageal puncture (TEP)** with voice prosthesis is the **gold standard** for voice rehabilitation post-laryngectomy. - A small fistula is created between trachea and esophagus, and a one-way valve (voice prosthesis) is inserted. - Air from the lungs is diverted through the prosthesis into the esophagus, vibrating the pharyngoesophageal segment to produce speech. - Provides the **most natural-sounding voice** among rehabilitation options. *Electrolarynx* - An **electrolarynx** is an external, battery-operated device held against the neck or placed intraorally that generates vibrations. - The vibrations are articulated by the mouth and tongue to produce speech. - Provides **immediate communication** post-laryngectomy, though the voice quality is mechanical or robotic.

Practice by Chapter

Salivary Gland Diseases

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Thyroid Gland Disorders

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Parathyroid Gland Disorders

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Neck Masses Evaluation

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Oral Cavity Lesions

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Laryngeal Disorders

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Head and Neck Cancer

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Reconstructive Techniques in Head and Neck Surgery

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Surgical Management of Sleep Apnea

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Airway Management in Head and Neck Surgery

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Surgical Approaches to the Neck

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Neck Dissection Techniques

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