Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 331: What is the most common presentation of nasopharyngeal carcinoma?

A. Loss of smell
B. Blockage of nose
C. Neck lymph node (Correct Answer)
D. Blood tinged discharge

Explanation: ***Neck lymph node*** - The most common initial symptom of nasopharyngeal carcinoma is a **painless neck mass** due to metastasis to cervical lymph nodes. - This occurs in a significant percentage of patients, often even before local symptoms from the primary tumor are prominent. *Loss of smell* - While possible in advanced stages if the tumor invades the **olfactory nerves** or directly obstructs the nasal cavity, it is not typically the initial or most common presentation. - This symptom is more indicative of conditions directly affecting the **olfactory epithelium** or nerves, not early nasopharyngeal carcinoma. *Blockage of nose* - **Nasal obstruction** or stuffiness can occur as the tumor grows and localizes within the nasopharynx, but it is less common as an initial symptom than a palpable neck mass. - This symptom might also be attributed to other common conditions like sinusitis or allergies, delaying diagnosis. *Blood tinged discharge* - **Epistaxis (nosebleeds)** or blood-tinged sputum/discharge can be a symptom, especially with later-stage tumors that are ulcerating or bleeding. - However, it is reported less frequently as the presenting symptom compared to cervical lymphadenopathy.

Question 332: A 6-year-old boy came to the hospital with complaints of sore throat and difficulty in swallowing. His left tonsil was pushed medially and had swelling over the left side upper part of neck. What will be the diagnosis?

A. Ludwig's angina
B. Peritonsillar abscess (Correct Answer)
C. Retropharyngeal abscess
D. Parapharyngeal abscess

Explanation: ***Peritonsillar abscess*** - A **peritonsillar abscess** (quinsy) is the most common deep neck space infection and characteristically causes **medial displacement of the tonsil**, which is the key clinical finding in this case. - The patient presents with classic features: severe unilateral sore throat, difficulty swallowing, and the hallmark sign of **tonsillar displacement medially**. - The swelling in the **upper lateral neck** can occur with peritonsillar abscess, especially when there is significant inflammation extending into the surrounding tissues. - Other typical features include trismus, "hot potato voice," and uvular deviation (though not mentioned here). *Parapharyngeal abscess* - A **parapharyngeal abscess** can develop as an extension of a peritonsillar abscess, but the primary finding would be **bulging of the lateral pharyngeal wall** rather than medial displacement of the tonsil itself. - While neck swelling is prominent in parapharyngeal abscess, the specific finding of **medial tonsillar displacement** is more characteristic of peritonsillar abscess. - Parapharyngeal abscess typically presents with more systemic toxicity and can involve cranial nerve complications. *Retropharyngeal abscess* - A **retropharyngeal abscess** typically causes severe dysphagia and odynophagia with posterior pharyngeal wall bulging. - It does not cause **medial displacement of the tonsil**, which is the key finding in this case. - Neck swelling would be more posterior and midline, and patients often present with neck hyperextension and respiratory distress. *Ludwig's angina* - **Ludwig's angina** is a severe bilateral cellulitis of the floor of the mouth involving the submandibular, sublingual, and submental spaces. - It characteristically causes painful swelling and **elevation of the tongue**, creating a "bull neck" appearance. - It does not cause **tonsillar displacement** or localized unilateral upper neck swelling as described in this case.

Question 333: Investigations used for CSF rhinorrhea are all except:

A. Skull X-ray (Correct Answer)
B. CT cisternogram
C. Beta-2 transferrin
D. Nasal endoscopy

Explanation: ***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.

Question 334: A 46-year-old patient develops a verrucous carcinoma in the oral cavity. What is true of this lesion?

A. It is best treated with radiation.
B. It is associated with a high metastatic rate.
C. It is ulcerating in appearance.
D. It is most commonly found on the inside of the cheek. (Correct Answer)

Explanation: ***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.

Question 335: 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?

A. Cystic dilation
B. Mikulicz's disease
C. Warthin tumor (Correct Answer)
D. Glandular hypertrophy, secondary to vitamin A deficiency

Explanation: ***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.

Question 336: Haemorrhage during tonsillectomy is usually from:

A. Facial artery
B. Ascending pharyngeal artery
C. Lingual artery
D. Paratonsillar vein (Correct Answer)

Explanation: ***Paratonsillar vein*** - The **paratonsillar veins** are the most common source of immediate bleeding during tonsillectomy, being superficial and directly encountered during **capsular dissection**. - These veins provide **venous drainage** from the tonsillar bed and are routinely injured during the surgical procedure, though bleeding is usually **easily controlled** with cautery or pressure. *Lingual artery* - The **tonsillar branch of the lingual artery** is more commonly associated with **late/secondary hemorrhage** occurring hours to days after surgery, not during the procedure. - While it can contribute to bleeding during surgery, it runs deeper in the **inferior tonsillar pole** and is less frequently the primary source of intraoperative hemorrhage. *Maxillary artery* - The **maxillary artery** is anatomically distant from the tonsillar fossa, running deep within the **infratemporal fossa**. - While its branches (like the **ascending pharyngeal artery**) can contribute to tonsillar bleeding, the main trunk itself is not a direct source during tonsillectomy. *Middle meningeal artery* - The **middle meningeal artery** supplies the **dura mater** and runs entirely within the **cranial cavity** through the foramen spinosum. - It has no anatomical relationship with the **oropharynx** or tonsillar fossa, making it impossible to be involved in tonsillectomy hemorrhage.

Question 337: Which cancer has maximum propensity to spread to cervical lymph nodes?

A. Carcinoma of soft palate
B. Carcinoma of hard palate
C. Nasopharyngeal carcinoma (Correct Answer)
D. Carcinoma of mandible

Explanation: ***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.

Question 338: Carcinoma tongue less than 2 cm is treated by -

A. Excision and Radiotherapy
B. Excision (Correct Answer)
C. Chemotherapy
D. Radiotherapy

Explanation: ***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.

Question 339: Which of the following is false about parotid tumor

A. Facial nerve involvement indicates malignancy
B. Malignant disease is most common variety (Correct Answer)
C. Pleomorphic adenoma is most common
D. Superficial parotidectomy is the treatment

Explanation: ***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.

Question 340: In benign intracranial hypertension-

A. Brain scan is not required in young women as sagittal sinus thrombosis is rare
B. There is a restriction of upgaze
C. Normal or small ventricles are characteristic findings (Correct Answer)
D. Optic nerve fenestration is one of the treatment options that should be considered early to prevent vision loss in benign intracranial hypertension

Explanation: ***Normal or small ventricles are characteristic findings*** - In benign intracranial hypertension (BIH/IIH), the **intracranial pressure (ICP) is elevated without a mass lesion or obstructive hydrocephalus**, resulting in **normal-sized or small ventricles** on imaging. - This is a **hallmark feature** of the condition and helps distinguish it from hydrocephalus where ventricles would be enlarged. - The presence of normal ventricles with elevated ICP and papilledema forms part of the **modified Dandy criteria** for diagnosing IIH. *Brain scan is not required in young women as sagittal sinus thrombosis is rare* - This is **incorrect** - brain imaging, particularly **MRI with MR venography (MRV)**, is **essential** in all cases of suspected BIH to exclude cerebral venous sinus thrombosis (CVST). - CVST is an important **secondary cause** of elevated ICP that can mimic IIH and is particularly relevant in young women (who are also the typical demographic for IIH). - **Excluding CVST and other secondary causes** is mandatory before diagnosing idiopathic intracranial hypertension. *There is a restriction of upgaze* - **Restriction of upgaze** is characteristic of **Parinaud's syndrome** (dorsal midbrain syndrome), typically caused by lesions affecting the superior colliculi (e.g., pineal region tumors). - BIH commonly causes **horizontal diplopia** from **sixth nerve palsy** (abducens nerve palsy) due to elevated ICP, but not upgaze restriction. *Optic nerve fenestration is one of the treatment options that should be considered early to prevent vision loss in benign intracranial hypertension* - This is **incorrect** - **optic nerve sheath fenestration (ONSF)** is a surgical procedure reserved for cases with **progressive vision loss despite maximal medical therapy**. - **First-line treatment** includes weight loss and **acetazolamide** (carbonic anhydrase inhibitor). - ONSF is a **late-stage intervention**, not an early treatment option, used when vision is severely threatened despite medical management.

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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