Head and Neck Surgery Practice Questions

Q: 65 year old man with carcinoma of tongue of > 4 cm size and multiple lymph nodes of > 6 cm noted. What is the AJCC staging?

T3 N3 M0. ***T3 N3 M0*** - The primary tumor (T) is classified as **T3** because its greatest dimension is greater than 4 cm (or any tumor with depth of invasion > 10 mm). - The nodal involvement (N) is classified as **N3** (specifically **N3a**) because any lymph node greater than 6 cm, regardless of number, qualifies as N3a per **AJCC 8th Edition** staging. - This is the correct staging based on the clinical findings provided. *T2 N3 M0* - This is incorrect because a tumor > 4 cm automatically classifies as **T3**, not T2. - **T2** is reserved for tumors > 2 cm but ≤ 4 cm with depth of invasion ≤ 10 mm, or tumors ≤ 2 cm with depth of invasion > 5 mm and ≤ 10 mm. - While the N3 classification is correct, the T staging is wrong. *T3 N2 M0* - This is incorrect because although **T3** is correct for a tumor > 4 cm, the nodal classification is wrong. - Any lymph node > 6 cm is classified as **N3a**, not N2. - **N2** classifications require all involved nodes to be ≤ 6 cm in size. *T2 N2 M0* - This is incorrect as both the T and N classifications are inaccurate. - A tumor > 4 cm is **T3**, not T2. - Lymph node(s) > 6 cm are **N3a**, not N2. - This represents understaging of both the primary tumor and nodal disease.

Q: A tumor in the cheek measuring 3 cm in size with contralateral mobile lymph nodes comes under:

T2N2M0. ***T2N2M0*** - A 3 cm tumor in the cheek is classified as **T2** for head and neck cancers, which designates a tumor greater than 2 cm but not exceeding 4 cm. - **Contralateral mobile lymph nodes** are classified as **N2c** if bilateral or contralateral nodes are involved and are ≤6 cm and mobile, which falls under the broader N2 classification. *T3N3M0* - **T3** generally refers to a tumor greater than 4 cm or with specific features like bone invasion in some sites, neither of which is present here. - **N3** indicates a lymph node greater than 6 cm in greatest dimension, or involving supraclavicular nodes, which is not described. *T3N2M0* - As explained, a 3 cm tumor is a **T2**, not a T3. - **N2** applies to the contralateral mobile lymph nodes, but the tumor size is incorrect for a T3 classification. *T4N2M0* - **T4** indicates a very large tumor (often >4 cm) or one with extensive invasion into adjacent structures, which is not the case for a 3 cm cheek tumor. - While **N2** may apply to the nodes, the T classification is incorrect.

Q: When bleeding doesn't stop on applying pressure and the patient has intermittent pain too, what should be the treatment taken into consideration?

Pulpectomy. ***Pulpectomy*** - **Uncontrolled bleeding** after applying pressure and **intermittent pain** are signs of **irreversible pulpitis** or pulp necrosis extending into the root canals. - A **pulpectomy** is indicated to remove the entire coronal and radicular pulp tissue to alleviate symptoms and prevent further infection. *Pulpotomy* - A **pulpotomy** is performed when active bleeding from the radicular pulp tissue can be controlled, indicating **reversible pulpitis** localized to the coronal pulp. - The goal is to preserve the vitality of the **radicular pulp**. *DPC* - **Direct pulp capping (DPC)** is indicated for small, mechanical pulp exposures in a tooth with a **healthy pulp** and no spontaneous pain. - It aims to preserve pulp vitality by placing a protective material directly over the exposed pulp. *None of the options* - Given the specific symptoms of **uncontrolled bleeding** and **intermittent pain**, a **pulpectomy** is a clearly indicated treatment option. - Therefore, it is incorrect to state that none of the options are applicable.

Q: Sistrunk operation is for:

Thyroglossal cyst. ***Thyroglossal cyst*** - The **Sistrunk operation** is the definitive surgical procedure for the removal of a **thyroglossal duct cyst**. - This procedure involves excising the cyst along with the central portion of the **hyoid bone** and a core of muscle from the posterior aspect of the hyoid to the foramen cecum to prevent recurrence. *Thyroglossal fistula* - A **thyroglossal fistula** is a complication of a thyroglossal cyst that has ruptured or been surgically incised, leading to a persistent tract to the skin. - While a Sistrunk operation may be performed for a fistula, it is primarily indicated for the *cyst* itself to prevent both recurrence of the cyst and subsequent fistula formation. *Branchial fistula* - A **branchial fistula** is a congenital anomaly resulting from incomplete closure of the branchial arches during embryonic development, leading to an abnormal tract between the neck and the pharynx or skin. - Surgical excision of a branchial fistula is a different procedure from the Sistrunk operation, as its anatomical location and developmental origin are distinct from those of a thyroglossal cyst. *Branchial cyst* - A **branchial cyst** is a congenital neck mass arising from remnants of the branchial arches, typically presenting as a painless, soft, movable lump in the lateral neck. - While also a congenital neck cyst requiring surgical excision, the surgical approach for a branchial cyst does not involve the hyoid bone in the same manner as the Sistrunk operation due to its different embryological origin and location.

Q: Treatment of resectable T4N0M0 stage of head and neck carcinoma is?

Surgery and Radiotherapy. ***Surgery and Radiotherapy*** - For **resectable T4N0M0 head and neck carcinoma**, the standard treatment is **surgical resection** of the primary tumor followed by **adjuvant radiotherapy**. - This approach achieves optimal **local control** for advanced primary tumors without nodal involvement. - **Adjuvant radiotherapy** is essential for T4 tumors due to high risk of microscopic residual disease and local recurrence. - Surgery allows for complete tumor removal with negative margins, while radiotherapy addresses subclinical disease. *Radiotherapy alone* - Radiotherapy alone is **insufficient as monotherapy** for T4 tumors due to the large tumor burden and extensive local invasion. - Single modality radiation cannot reliably achieve adequate tumor control for advanced primary lesions. - Generally reserved for early-stage disease or patients unfit for surgery. *Chemoradiation* - **Definitive chemoradiation** is an alternative for **unresectable T4 tumors** or when organ preservation is desired (e.g., laryngeal cancer). - For **resectable** T4N0M0 disease, surgery with adjuvant RT is preferred as it provides better local control and allows pathological staging. - Chemoradiation may be used postoperatively if high-risk features are found (positive margins, perineural invasion, extranodal extension). - In this **N0 case with resectable tumor**, upfront surgery is the preferred initial approach. *Surgery alone* - While surgical resection is crucial for T4 tumors, **surgery alone is inadequate** due to high risk of locoregional recurrence. - T4 classification indicates extensive local invasion, necessitating **adjuvant radiotherapy** to eradicate microscopic disease. - Combined modality treatment (surgery + RT) significantly improves local control and survival compared to surgery alone.

Q: The elevator can be used to advantage when:

Multiple adjacent teeth are to be extracted.. ***Multiple adjacent teeth are to be extracted.*** - Elevators are highly effective in situations requiring the extraction of **multiple adjacent teeth** because they can leverage the adjacent alveolar bone and PDL space for mechanical advantage. - Using an elevator in such cases helps to progressively loosen each tooth, making subsequent extractions easier and often less traumatic. *The tooth to be extracted is isolated.* - While an elevator can be used on an isolated tooth, its greatest advantage, which is **gaining leverage from an adjacent tooth or bone**, is diminished. - In isolation, the primary action becomes luxation within the socket, which can be achieved but might not be the most efficient use of the elevator's specific design. *The adjacent tooth is not to be extracted.* - Using an elevator when the adjacent tooth is not to be extracted poses a significant risk of **damaging the periodontal ligament or even the enamel and dentin** of the healthy neighboring tooth. - The principle of using an elevator involves applying force against an adjacent structure, and if that structure is to be preserved, this approach is contraindicated. *The interdental bone is used as a fulcrum.* - While interdental bone can indeed be used as a fulcrum for elevators, the wording of this option doesn't fully capture the *advantageous scenario* for using an elevator as effectively as extracting multiple adjacent teeth. - The primary benefit of using an elevator often lies in its ability to **luxate a tooth by wedging into the periodontal ligament space**, and using **interdental bone as a fulcrum** is a technique that can be applied, but it is optimized when multiple teeth are being removed to prevent unnecessary bone loss around a single tooth.

Q: True about tongue cancer:

MC site is on Lateral margin. ***MC site is on Lateral margin*** - The **lateral border** of the tongue is the most common site for squamous cell carcinoma (SCC) of the tongue due to chronic irritation and exposure to carcinogens. - This anatomical location makes it susceptible to tumor development due to constant friction and potential for trauma. *Slurring of speech is a common complaint* - While speech can be affected by advanced tongue cancer, **dysarthria** (slurring of speech) is not typically an early or primary complaint. - Early symptoms often include a **painless lesion**, ulcer, or lump on the tongue. *Cervical lymph node metastasis is universally present* - While **cervical lymph node metastasis** is common in tongue cancer, its presence is not universal at diagnosis. - The incidence of metastasis varies depending on tumor size, depth of invasion, and location, ranging from 30% to 50% in early stages. *Most common type is adenocarcinoma* - The vast majority of tongue cancers, over 90%, are **squamous cell carcinomas (SCCs)**, arising from the epithelial cells. - **Adenocarcinoma** is a rare type of tongue cancer, originating from glandular tissue, and is not the most common histological type.

Q: Most of the parotid tumors are managed by:

Superficial parotidectomy. ***Superficial parotidectomy*** - The vast majority of parotid tumors, especially **benign tumors** like **pleomorphic adenomas**, arise in the **superficial lobe** of the parotid gland. - This procedure removes the superficial lobe while preserving the **facial nerve**, which is crucial for facial expression. - **Most common procedure** for parotid tumors since 80-85% are benign and superficial. *Total parotidectomy* - This procedure removes both the **superficial and deep lobes** of the parotid gland. - Typically reserved for tumors affecting the **deep lobe** or those with extensive involvement. - Less common than superficial parotidectomy as deep lobe tumors are uncommon. *Radical parotidectomy & Neck dissection* - **Radical parotidectomy** involves removing the entire parotid gland, often sacrificing the **facial nerve**, and a **neck dissection** removes lymph nodes in the neck. - This aggressive approach is reserved for **malignant tumors** with known or suspected **nodal metastasis**. - Represents a small percentage of parotid tumor cases. *Radical parotidectomy* - This procedure involves removal of the entire parotid gland, often including the **facial nerve** or its branches, due to tumor infiltration. - Indicated for **high-grade malignant tumors** with nerve involvement but without overt nodal metastasis. - Less common than benign superficial tumors requiring only superficial parotidectomy.

Q: Branchial cleft anomalies are present at birth or shortly after birth. Which of the following is TRUE about branchial anomaly?

Most commonly due to 2nd branchial remnants. ***Most commonly due to 2nd branchial remnants*** - **Second branchial cleft anomalies** are the most prevalent type, accounting for approximately **90-95%** of all branchial anomalies. - They typically present as cysts, sinuses, or fistulas along the anterior border of the **sternocleidomastoid muscle**. *Fistulas are more common than cysts* - **Cysts** are actually the most common presentation of branchial anomalies, often appearing as solitary masses. - While fistulas and sinuses can occur, they are generally **less frequent** than isolated cysts. *For sinuses surgery is not always indicated* - **Surgical excision** is generally indicated for all branchial anomalies, including sinuses, due to the risk of **infection**, recurrence, and potential for an underlying fistula. - Conservative management is typically reserved for infected cysts (drainage and antibiotics) before definitive surgical removal. *Cysts present with dysphagia and hoarseness of voice* - **Dysphagia** (difficulty swallowing) and **hoarseness of voice** are not typical symptoms of branchial cleft cysts, as these cysts are usually located laterally in the neck. - These symptoms are more commonly associated with congenital anomalies affecting the **pharynx**, **larynx**, or **thyroid gland** (e.g., thyroglossal duct cysts when large or infected).

Question 1

65 year old man with carcinoma of tongue of > 4 cm size and multiple lymph nodes of > 6 cm noted. What is the AJCC staging?

Accepted Answer

T3 N3 M0

Answer

T2 N3 M0

Answer

T3 N2 M0

Answer

T2 N2 M0

Question 2

A tumor in the cheek measuring 3 cm in size with contralateral mobile lymph nodes comes under:

Accepted Answer

T2N2M0

Answer

T3N3M0

Answer

T3N2M0

Answer

T4N2M0

Question 3

When bleeding doesn't stop on applying pressure and the patient has intermittent pain too, what should be the treatment taken into consideration?

Accepted Answer

Pulpectomy

Answer

Pulpotomy

Answer

DPC

Answer

None of the options

Question 4

Sistrunk operation is for:

Accepted Answer

Thyroglossal cyst

Answer

Thyroglossal fistula

Answer

Branchial fistula

Answer

Branchial cyst

Question 5

Treatment of stage III carcinoma of oral tongue is:

Accepted Answer

Wide excision with supraomohyoid neck dissection and post-operative radiotherapy

Answer

Wide excision

Answer

Radiotherapy delivering 7000 cGy

Answer

Wide excision with supraomohyoid neck dissection

Question 6

Treatment of resectable T4N0M0 stage of head and neck carcinoma is?

Accepted Answer

Surgery and Radiotherapy

Answer

Radiotherapy alone

Answer

Chemoradiation

Answer

Surgery alone

Question 7

The elevator can be used to advantage when:

Accepted Answer

Multiple adjacent teeth are to be extracted.

Answer

The tooth to be extracted is isolated.

Answer

The adjacent tooth is not to be extracted.

Answer

The interdental bone is used as a fulcrum.

Question 8

True about tongue cancer:

Accepted Answer

MC site is on Lateral margin

Answer

Slurring of speech is a common complaint

Answer

Cervical lymph node metastasis is universally present

Answer

Most common type is adenocarcinoma

Question 9

Most of the parotid tumors are managed by:

Accepted Answer

Superficial parotidectomy

Answer

Total parotidectomy

Answer

Radical parotidectomy & Neck dissection

Answer

Radical parotidectomy

Question 10

Branchial cleft anomalies are present at birth or shortly after birth. Which of the following is TRUE about branchial anomaly?

Accepted Answer

Most commonly due to 2nd branchial remnants

Answer

Fistulas are more common than cysts

Answer

For sinuses surgery is not always indicated

Answer

Cysts present with dysphagia and hoarseness of voice

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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