Head and Neck Surgery Practice Questions

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

Inferior nasal meatus. ***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.

Q: CSF rhinorrhea is diagnosed by: MP 07

Beta-2 transferrin. ***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

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

Metastasis in a lymph node >6 cm. ***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.

Q: Which among the following parotid tumors spreads through neural sheath

Adenocystic ca. ***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.

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

Deviation of the mandible to the left on protrusion. ***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.

Q: All are true about nasolabial cysts except

Derived from odontogenic epithelium. ***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.

Q: Not true about glottic carcinoma

Has worst prognosis. ***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.

Q: Which of the following is more prone to osteomyelitis?

Mandible. ***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.

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

Total laryngectomy with radiotherapy. ***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.

Question 1

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

Accepted Answer

Inferior nasal meatus

Answer

Middle nasal meatus

Answer

Nasolacrimal duct

Answer

Superior nasal meatus

Question 2

CSF rhinorrhea is diagnosed by: MP 07

Accepted Answer

Beta-2 transferrin

Answer

Halo sign

Answer

Glucose estimation

Answer

All of the options

Question 3

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

Accepted Answer

Metastasis in a lymph node >6 cm

Answer

Metastasis in lymph nodes >2 cm

Answer

Metastasis in lymph nodes >5 cm

Answer

None of the options

Question 4

Which among the following parotid tumors spreads through neural sheath

Accepted Answer

Adenocystic ca

Answer

Sq cell ca

Answer

Mixed parotid tumour

Answer

Lymphoma

Question 5

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

Accepted Answer

Deviation of the mandible to the left on protrusion

Answer

Inability to deviate the mandible to the right

Answer

Moderate intraoral bleeding

Answer

Trismus and bilateral crepitus

Question 6

All are true about nasolabial cysts except

Accepted Answer

Derived from odontogenic epithelium

Answer

They are usually unilateral

Answer

More common in females

Answer

Present in adults

Question 7

Not true about glottic carcinoma

Accepted Answer

Has worst prognosis

Answer

Is most common site in carcinoma larynx

Answer

Presents early

Answer

Most common in males

Question 8

Which of the following is more prone to osteomyelitis?

Accepted Answer

Mandible

Answer

Maxilla

Answer

Palatine bone

Answer

Zygoma

Question 9

Regarding parotid neoplasms, the false statement is

Accepted Answer

FNA has low sensitivity and specificity in diagnosing parotid neoplasms

Answer

Enucleation leads to recurrence

Answer

Pain may be a pointer for malignancy

Answer

Deep lobe tumors can present with trismus as early presentation

Question 10

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

Accepted Answer

Total laryngectomy with radiotherapy

Answer

Total laryngectomy

Answer

Radiotherapy

Answer

Hemilaryngectomy

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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