Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 341: In dacrocystorhinostomy (DCR) lacrimal sacs are directly opened into:

A. Middle nasal meatus
B. Inferior nasal meatus (Correct Answer)
C. Nasolacrimal duct
D. Superior nasal meatus

Explanation: ***Inferior nasal meatus*** - In **dacrocystorhinostomy (DCR)**, a new connection is created between the **lacrimal sac** and the **nasal cavity** to bypass an obstructed nasolacrimal duct. - The lacrimal sac is opened directly into the **inferior nasal meatus** (or the junction of inferior and middle meatus), maintaining the natural anatomical drainage pathway. - This location corresponds to where the nasolacrimal duct would normally drain, providing effective tear drainage. *Middle nasal meatus* - The middle nasal meatus is located **superior** to the typical DCR anastomosis site. - While the ostium may extend slightly toward the middle meatus in some cases, the primary drainage opening is into the **inferior meatus**. - The middle meatus primarily receives drainage from the maxillary, frontal, and anterior ethmoid sinuses. *Nasolacrimal duct* - The purpose of DCR is to **bypass a blocked nasolacrimal duct**, not to open into it. - The procedure creates a new pathway from the lacrimal sac directly to the nasal cavity, circumventing the obstructed duct. *Superior nasal meatus* - The **superior nasal meatus** is located in the upper nasal cavity and receives drainage from the posterior ethmoid air cells. - It is **not** the anatomical site for DCR surgery, as this would be too superior and would not provide an effective drainage pathway for lacrimal fluid.

Question 342: CSF rhinorrhea is diagnosed by: MP 07

A. Halo sign
B. Glucose estimation
C. Beta-2 transferrin (Correct Answer)
D. All of the options

Explanation: ***Beta-2 transferrin*** - **Beta-2 transferrin** is the **gold standard** for diagnosing CSF rhinorrhea with **high specificity and sensitivity** - It is present **only in CSF, perilymph, and aqueous humor**, making it highly specific for CSF leak diagnosis - While it requires specialized laboratory analysis and may not be immediately available, it remains the **most reliable confirmatory test** - Modern alternatives include **Beta-trace protein**, which also has high specificity *Glucose estimation* - Historically used as a rapid screening test based on the presence of glucose in CSF - **Major limitation**: **Poor specificity** as nasal mucus, tears, and other secretions also contain glucose, leading to frequent false positives - A positive glucose test is suggestive but **not diagnostic** and requires confirmation with more specific tests - No longer considered the primary diagnostic method due to high false-positive rates *Halo sign* - The **halo sign** (or double ring sign) appears when nasal discharge mixed with blood is placed on filter paper, creating a central blood spot with a clear surrounding ring - **Not specific for CSF** - other watery fluids (tears, saline) mixed with blood can produce similar appearance - Useful as a **bedside screening test** but requires confirmation with biochemical analysis *All of the options* - While multiple tests can be used in the diagnostic workup, they have **different specificities and diagnostic values** - **Beta-2 transferrin** is the definitive diagnostic test, while others serve as screening or supportive tests - Therefore, "All of the options" is incorrect as the question asks for the diagnostic test, which specifically refers to the gold standard

Question 343: N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:

A. Metastasis in a lymph node >6 cm (Correct Answer)
B. Metastasis in lymph nodes >2 cm
C. Metastasis in lymph nodes >5 cm
D. None of the options

Explanation: ***Metastasis in a lymph node >6 cm*** - **N3a disease** in head and neck cancer staging (AJCC 8th edition) specifically refers to metastasis in a single lymph node larger than 6 cm in greatest dimension **without extranodal extension (ENE)**. - This applies to oral cavity, oropharynx (HPV-negative), hypopharynx, and larynx cancers. - **Note:** N3 staging also includes **N3b** (metastasis in any node with clinically overt ENE), but this question specifically asks about N3a criteria. *Metastasis in lymph nodes >2 cm* - Lymph nodes in the 2-3 cm range typically fall within **N1 or N2a categories**, depending on laterality and number of involved nodes. - **N3a disease** requires a single lymph node to exceed 6 cm in greatest dimension without ENE. *Metastasis in lymph nodes >5 cm* - A lymph node between 3-6 cm is usually classified as **N2 disease** (N2a if single ipsilateral ≤6 cm, N2b if multiple ipsilateral ≤6 cm, N2c if bilateral or contralateral ≤6 cm). - To be classified as **N3a**, the lymph node must be **>6 cm** without extranodal extension. *None of the options* - This option is incorrect because the first option accurately describes the size criterion for **N3a TNM staging** in head and neck tumors according to AJCC 8th edition guidelines. - While N3 staging has two subcategories (N3a and N3b), the size criterion of >6 cm correctly defines N3a disease.

Question 344: Which among the following parotid tumors spreads through neural sheath

A. Sq cell ca
B. Mixed parotid tumour
C. Adenocystic ca (Correct Answer)
D. Lymphoma

Explanation: ***Adenocystic ca*** - **Adenoid cystic carcinoma** is notoriously known for its propensity for **perineural invasion**, meaning it spreads along nerve sheaths, leading to high recurrence rates and difficulty in complete eradication. - This characteristic spread pattern allows the tumor to infiltrate adjacent tissues beyond its apparent margins, often resulting in **neurological symptoms** like pain or paralysis. *Sq cell ca* - **Squamous cell carcinoma** (SCC) of the parotid gland is typically aggressive and spreads through **lymphatic and hematogenous routes**, as well as direct extension, but perineural invasion is not its primary mode of spread. - While SCC can invade nerves, it is not as defining a feature as it is for adenoid cystic carcinoma, and its aggressiveness is more often related to its rapid growth and tendency for **lymph node metastasis**. *Mixed parotid tumour* - A **mixed parotid tumor**, also known as a **pleomorphic adenoma**, is typically a **benign tumor** that grows slowly and expansively. - While a malignant transformation (carcinoma ex pleomorphic adenoma) can occur, primary mixed tumors do not spread through **neural sheaths**. *Lymphoma* - **Lymphoma** in the parotid gland is a **hematopoietic malignancy** that primarily involves lymphoid tissue. - Its spread typically occurs via the **lymphatic system** to regional lymph nodes and other lymphoid organs, rather than direct perineural invasion.

Question 345: An adult patient sustained a subcondylar fracture on the left side. Clinically it is seen that there is :

A. Deviation of the mandible to the left on protrusion (Correct Answer)
B. Inability to deviate the mandible to the right
C. Moderate intraoral bleeding
D. Trismus and bilateral crepitus

Explanation: ***Deviation of the mandible to the left on protrusion*** - A **subcondylar fracture on the left side** disrupts the normal function of the left lateral pterygoid muscle and the biomechanics of mandibular movement. - During protrusion or mouth opening, the **intact muscles on the right side** pull normally while the fractured left side cannot, causing the mandible to deviate **toward the fractured side (left)**. - This is the **classic clinical sign** of unilateral subcondylar fracture - deviation toward the affected side during protrusion and opening. *Inability to deviate the mandible to the right* - This is **not correct** for a left subcondylar fracture. - The patient would have difficulty deviating to the **left side** (fractured side), not to the right. - Lateral deviation to the contralateral (right) side would still be possible. *Moderate intraoral bleeding* - While some **intraoral bleeding** can occur with mandibular fractures due to soft tissue injury, **moderate bleeding** is not a specific or primary clinical sign of an isolated subcondylar fracture. - Subcondylar fractures are typically **extracapsular** and often present without significant intraoral hemorrhage. *Trismus and bilateral crepitus* - **Trismus** (limited mouth opening) is common with subcondylar fractures due to muscle spasm and pain. - However, **bilateral crepitus** is unlikely with a **unilateral** subcondylar fracture. - Crepitus would typically be localized to the **left side only**, and bilateral crepitus suggests bilateral fractures or more extensive trauma.

Question 346: All are true about nasolabial cysts except

A. Derived from odontogenic epithelium (Correct Answer)
B. They are usually unilateral
C. More common in females
D. Present in adults

Explanation: ***Derived from odontogenic epithelium*** - This statement is **false**, making it the correct answer, as nasolabial cysts are theorized to originate from the **nasolacrimal duct epithelium** or embryonic facial fissures, not odontogenic epithelium. - Cysts derived from **odontogenic epithelium** are typically found within the jawbones or associated with teeth. *They are usually unilateral* - Nasolabial cysts are indeed **unilateral** in the vast majority of cases, presenting as a soft tissue swelling in the nasolabial fold area. - While rare, **bilateral cases** have been reported but are not the typical presentation. *More common in females* - There is a recognized higher prevalence of nasolabial cysts in **females**, often with a female-to-male ratio of 3:1 or 4:1. - The exact reason for this gender predilection is not fully understood. *Present in adults* - Nasolabial cysts typically present in **adults**, most commonly in the fourth to fifth decades of life. - They are rarely seen in **children** or adolescents.

Question 347: Not true about glottic carcinoma

A. Is most common site in carcinoma larynx
B. Presents early
C. Has worst prognosis (Correct Answer)
D. Most common in males

Explanation: ***Has worst prognosis*** - Glottic carcinoma generally has a **good prognosis** due to its early presentation with hoarseness and relative lack of lymphatic dissemination. - The statement that it has the **worst prognosis** among laryngeal carcinomas is incorrect; supraglottic and subglottic carcinomas often have poorer prognoses. *Is most common site in carcinoma larynx* - The **glottis** (true vocal cords) is indeed the **most common site** for laryngeal squamous cell carcinoma, accounting for about 60-70% of cases. - This anatomical location is prone to neoplastic changes due to exposure to carcinogens. *Presents early* - Glottic carcinoma typically presents **early** with **hoarseness of voice** as the tumor interferes with vocal cord vibration. - This early symptom often leads to prompt medical attention, allowing for early diagnosis and treatment. *Most common in males* - Laryngeal carcinoma, including glottic carcinoma, is significantly **more common in males** than females, with a male-to-female ratio of about 4:1. - This gender disparity is primarily attributed to higher rates of smoking and alcohol consumption in men. *Has good prognosis due to least lymphatic supply.* - The **glottis** has a relatively **sparse lymphatic drainage** compared to the supraglottis and subglottis. - This limited lymphatic supply leads to a lower risk of **early nodal metastasis**, contributing to the overall good prognosis.

Question 348: Which of the following is more prone to osteomyelitis?

A. Mandible (Correct Answer)
B. Maxilla
C. Palatine bone
D. Zygoma

Explanation: ***Mandible*** - The **mandible** is more prone to osteomyelitis due to its **dense cortical bone** and relatively **poor blood supply** compared to other facial bones. - This limited vascularity makes it harder for the immune system to clear infections, increasing the risk of **bacterial colonization** and bone destruction. *Maxilla* - The **maxilla** has a **richer blood supply** and more **cancellous bone**, which provides better vascularity and resistance to infection. - Its anatomical structure allows for better drainage and immune response, making osteomyelitis less common than in the mandible. *Palatine bone* - The **palatine bone** is relatively small and well-protected, with a good blood supply from surrounding vessels. - Cases of osteomyelitis in the palatine bone are rare and typically occur as a result of severe systemic infections or direct trauma. *Zygoma* - The **zygoma** (cheekbone) is primarily composed of compact bone but has a robust blood supply. - Osteomyelitis of the zygoma is uncommon and usually linked to direct trauma, compound fractures, or extension from adjacent infected structures.

Question 349: Regarding parotid neoplasms, the false statement is

A. FNA has low sensitivity and specificity in diagnosing parotid neoplasms (Correct Answer)
B. Enucleation leads to recurrence
C. Pain may be a pointer for malignancy
D. Deep lobe tumors can present with trismus as early presentation

Explanation: ***FNA has low sensitivity and specificity in diagnosing parotid neoplasms*** - **Fine needle aspiration (FNA)** is actually a highly sensitive and specific diagnostic tool for evaluating parotid gland masses, typically achieving sensitivity and specificity rates of over 90%. - It helps in distinguishing between inflammatory, benign, and malignant lesions with good accuracy, guiding subsequent management. - **This is the FALSE statement** - FNA actually has HIGH sensitivity and specificity. *Deep lobe tumors can present with trismus as early presentation* - **Trismus** (difficulty opening the mouth) is associated with **deep lobe parotid tumors** or tumors that invade adjacent masticator muscles or the pterygoid plates. - Deep lobe tumors can cause trismus when they extend toward or compress the muscles of mastication. - **This is a TRUE statement** - deep lobe involvement can cause trismus. *Enucleation leads to recurrence* - **Enucleation**, which involves simply shelling out the tumor without a cuff of healthy tissue, is associated with a significantly higher recurrence rate for benign parotid tumors, especially **pleomorphic adenomas** (20-45% recurrence). - The standard surgical approach for benign parotid tumors is **superficial parotidectomy** or partial parotidectomy to ensure clear margins and reduce recurrence. - **This is a TRUE statement** - enucleation does increase recurrence risk. *Pain may be a pointer for malignancy* - **Pain** associated with a parotid mass is a concerning symptom and often indicates **malignancy**, especially if it is persistent and progressive. - Benign parotid tumors are typically painless and slow-growing unless they become very large or inflamed. - **This is a TRUE statement** - pain is a red flag for malignancy.

Question 350: Stage IVa with thyroid cartilage invasion in laryngeal carcinoma is treated with:

A. Total laryngectomy
B. Radiotherapy
C. Total laryngectomy with radiotherapy (Correct Answer)
D. Hemilaryngectomy

Explanation: ***Total laryngectomy with radiotherapy*** - **Stage IVa laryngeal carcinoma** with **thyroid cartilage invasion** is considered advanced disease requiring aggressive treatment. - **Multimodal therapy** combining surgical resection (total laryngectomy) to remove the tumor and adjuvant radiotherapy to address microscopic disease and reduce recurrence is the standard of care. *Total laryngectomy* - While a **total laryngectomy** is necessary to remove the primary tumor with cartilage invasion, it often requires additional (adjuvant) therapy like radiation to improve local control and survival rates. - Relying solely on surgery for **Stage IVa disease** may not adequately address potential microscopic spread, leading to higher recurrence rates. *Radiotherapy* - **Radiotherapy alone** is typically reserved for early-stage laryngeal cancers or as a palliative measure for advanced, unresectable disease. - In Stage IVa with **thyroid cartilage invasion**, radiation alone is insufficient due to the bulk of the disease and high risk of local recurrence. *Hemilaryngectomy* - A **hemilaryngectomy** is a partial removal of the larynx, suitable for much smaller, early-stage tumors that are confined to one side of the larynx, without cartilage invasion. - It is inadequate for **Stage IVa disease** with cartilage invasion due to the extensive nature of the tumor.

Practice by Chapter

Salivary Gland Diseases

Practice Questions

Thyroid Gland Disorders

Practice Questions

Parathyroid Gland Disorders

Practice Questions

Neck Masses Evaluation

Practice Questions

Oral Cavity Lesions

Practice Questions

Laryngeal Disorders

Practice Questions

Head and Neck Cancer

Practice Questions

Reconstructive Techniques in Head and Neck Surgery

Practice Questions

Surgical Management of Sleep Apnea

Practice Questions

Airway Management in Head and Neck Surgery

Practice Questions

Surgical Approaches to the Neck

Practice Questions

Neck Dissection Techniques

Practice Questions

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