Head and Neck Surgery Practice Questions

Q: Which nerve needs to be carefully identified during parotid gland surgery?

Facial nerve. ***Facial nerve*** - The **facial nerve (cranial nerve VII)** passes directly through the substance of the parotid gland, dividing it into superficial and deep lobes. - Damage to the facial nerve during surgery can result in **facial paralysis**, affecting muscle movement for expression. *Trigeminal nerve* - The **trigeminal nerve (cranial nerve V)** primarily provides sensation to the face and controls muscles of mastication. - It does not course through the parotid gland itself, so direct injury during parotidectomy is less likely. *Greater petrosal nerve* - The **greater petrosal nerve** is a branch of the facial nerve that carries preganglionic parasympathetic fibers to the lacrimal gland. - It originates within the skull and does not traverse the parotid gland, making it an unlikely nerve to be directly injured during parotidectomy. *Chorda tympani* - The **chorda tympani** is another branch of the facial nerve, conveying taste sensation from the anterior two-thirds of the tongue and parasympathetic fibers to the submandibular and sublingual glands. - It does not pass through the parotid gland but is located more medially within the middle ear and infratemporal fossa.

Q: Nerve most commonly damaged in radical mastoidectomy is -

Facial. ***Facial*** - The **facial nerve (cranial nerve VII)** runs through the temporal bone in close proximity to the operative field during a radical mastoidectomy. - Due to its anatomical course through the middle ear and mastoid, it is the most vulnerable nerve to iatrogenic injury during this procedure, leading to **facial paralysis**. *Cochlear* - The **cochlear nerve** is responsible for hearing and is located deeper within the inner ear (cochlea). - While damage to the inner ear structures can cause hearing loss, direct injury to the cochlear nerve itself is less common during a mastoidectomy compared to the facial nerve. *Vestibular* - The **vestibular nerve** is responsible for balance and is part of the vestibulocochlear nerve (cranial nerve VIII), located in the inner ear. - Damage to the vestibular nerve or associated structures can cause **vertigo and imbalance**, but direct injury to the nerve during mastoidectomy is less common than facial nerve injury. *All of the options* - While damage to the cochlear and vestibular nerves (leading to hearing loss or balance issues) can occur with extensive or complicated mastoid surgery affecting the inner ear, the **facial nerve** is by far the most frequently implicated and specifically vulnerable nerve during a radical mastoidectomy due to its anatomical course. - Therefore, it is incorrect to state that all these nerves are equally or most commonly damaged.

Q: A patient with head and neck cancer has a contralateral lymph node of 3 cm size. What is the N staging?

N2c Single or Multiple Bilateral or Contralateral None > 6 cm. ***N2c (Single or Multiple, Bilateral or Contralateral, None > 6 cm)*** - A 3 cm **contralateral** lymph node falls under the **N2c** category according to the AJCC staging system for head and neck cancers. - **N2c** indicates involvement of **contralateral** or **bilateral lymph nodes**, with the largest node being **no greater than 6 cm**. - This is the correct staging for the described clinical scenario. *N2a (Single, Ipsilateral, 3 to 6 cm)* - This option incorrectly describes an **ipsilateral** lymph node, whereas the question specifies a **contralateral** node. - **N2a** is defined by a single **ipsilateral** lymph node between **3 and 6 cm** in greatest dimension. - The key differentiator is **laterality** (ipsilateral vs contralateral). *N1 (Single, Ipsilateral, Equal to or <3 cm)* - This option refers to an **ipsilateral** lymph node that is **3 cm or smaller**, which does not match the contralateral location provided in the question. - **N1** describes a single **ipsilateral** lymph node that is **≤ 3 cm** in greatest dimension. - This fails on both **laterality** (ipsilateral vs contralateral) and **size criteria** (the node is exactly 3 cm, at the boundary). *N3 (Single or Multiple, Ipsilateral/Bilateral/Contralateral, Any node >6 cm)* - While it includes contralateral involvement, **N3** is specifically for a lymph node **greater than 6 cm**, which is not the case for a 3 cm node. - A **N3** classification applies when **any** regional lymph node (ipsilateral, bilateral, or contralateral) exceeds **6 cm** in greatest dimension. - The described 3 cm node does not meet the **size threshold** for N3 staging.

Q: Pell and Gregory classification includes all of the following except:

Root size.. ***Root size*** - The Pell and Gregory classification for impacted mandibular third molars assesses the **spatial relationship** between the impacted tooth and surrounding structures - It specifically evaluates: (1) **Class I-III** based on the relationship to the ramus and second molar, and (2) **Position A-C** based on depth relative to the occlusal plane - **Root size and morphology** are NOT parameters in this classification system, making this the correct answer *Angulation of 3rd molar* - While angulation is important in surgical planning, it is classified by **Winter's classification** (mesioangular, distoangular, vertical, horizontal), not by Pell and Gregory - However, Pell and Gregory does assess the **position** of the tooth, which is different from its angulation *Height of mandible* - The Pell and Gregory classification indirectly relates to mandibular dimensions through its assessment of available **anteroposterior space** - **Class I:** Sufficient space between distal of 2nd molar and anterior border of ramus - **Class II:** Space is less than the mesiodistal width of the 3rd molar crown - **Class III:** 3rd molar is completely within the ramus *Relationship to adjacent teeth* - The Pell and Gregory classification specifically includes the **spatial relationship** of the impacted 3rd molar to the 2nd molar and the ascending ramus - This relationship to adjacent structures is a fundamental component of the classification

Q: Which of the following are stress bearing areas?

Slope of residual ridge, buccal shelf area and hard palate. ***Slope of residual ridge, buccal shelf area and hard palate*** - The **buccal shelf area** in the mandible and the **hard palate** in the maxilla are primary stress-bearing areas due to their dense cortical bone and perpendicular resistance to occlusal forces. - The **slopes of the residual ridge** (particularly the posterior slopes) can also contribute to stress distribution, especially in larger residual ridges. *Buccal shelf area, incisive papilla and palatine rugae* - While the **buccal shelf area** is a primary stress-bearing region, the **incisive papilla** and **palatine rugae** are not. - The **incisive papilla** is a pressure-sensitive area, and the **palatine rugae** are secondary support areas, not designed for primary stress bearing. *Slopes of residual ridge, palatine rugae and midpalatine raphe* - The **slopes of the residual ridge** can contribute to stress bearing, especially in the mandible, but the **palatine rugae** and **midpalatine raphe** are not primary stress-bearing areas. - The **midpalatine raphe** is a non-yielding bony area covered by thin mucosa, making it intolerant to heavy force. *Incisive papilla, slope of the residual ridge and crest of the residual ridge* - The **incisive papilla** is a pressure-sensitive area and the **crest of the residual ridge** is generally a secondary stress-bearing area (or even a relief area if severely atrophied) due to its composition of cancellous bone and thin mucosa. - While the **slope of the residual ridge** can bear some stress, the inclusion of the incisive papilla and the crest as primary bearers makes this option incorrect for the most significant stress-bearing areas.

Q: Lynch-Howarth surgery is for:

Sinonasal tumors. ***Sinonasal tumors*** - The Lynch-Howarth incision (also known as the **external ethmoidectomy approach** or **Lynch incision**) is a surgical approach specifically used for accessing and resecting **lesions of the ethmoid and frontal sinuses**, which commonly include sinonasal tumors. - It provides direct exposure to the **ethmoid labyrinth**, **medial orbit**, and **frontal sinus floor**. *Otosclerosis* - Otosclerosis is a disease of the **ossicles in the middle ear** that causes progressive conductive hearing loss. - The standard surgical treatment for otosclerosis is **stapedectomy** or **stapedotomy**, which involves replacing a portion of the stapes bone. *Nasal septal perforation* - A nasal septal perforation is a hole in the **nasal septum**. - Surgical repair typically involves various **flap techniques** (e.g., mucoperichondrial flaps) to cover the defect, not the Lynch-Howarth approach. *Acoustic neuroma* - An acoustic neuroma (vestibular schwannoma) is a **benign tumor of the eighth cranial nerve**. - Surgical removal typically involves **translabyrinthine**, **retrosigmoid**, or **middle fossa** approaches, none of which utilize the Lynch-Howarth incision.

Q: What type of fracture of petrous temporal bone has the highest chance of facial nerve paralysis?

Transverse. ***Transverse*** - **Transverse fractures** of the petrous temporal bone run perpendicular to the long axis of the petrous bone and are typically caused by direct blows to the occiput or high-energy trauma. - These fractures have the **highest incidence (30-50%)** of facial nerve paralysis due to direct involvement of the facial nerve within the petrous canal, often resulting in complete and immediate paralysis from transection or severe crush injury. *All have equal incidence* - This is incorrect because the incidence of facial nerve paralysis varies significantly depending on the **type and direction of the fracture** pattern. - Different fracture orientations impact the facial nerve's intricate intratemporal course in distinct ways, resulting in markedly different injury rates. *Oblique* - **Oblique fractures** are less common and their impact on the facial nerve is variable, generally considered intermediate between longitudinal and transverse fractures. - The specific angulation and degree of facial canal involvement determine the risk, but the incidence is typically lower than transverse fractures. *Longitudinal* - **Longitudinal fractures** run parallel to the long axis of the petrous bone, typically resulting from lateral temporal impacts. - These fractures have a **much lower incidence (10-20%)** of facial nerve paralysis, usually incomplete and often due to edema or hematoma rather than direct nerve transection, as they tend to spare the facial nerve's intratemporal course.

Q: Topical mitomycin C is used to aid the following treatment:

Treatment of laryngotracheal stenosis. ***Treatment of laryngotracheal stenosis*** - **Mitomycin C** is an **antimitotic** agent that inhibits DNA synthesis, reducing **fibroblast proliferation** and collagen synthesis. - In laryngotracheal stenosis, it is applied topically to inhibit scar tissue formation and recurrence after surgical or endoscopic intervention. *Endoscopic treatment of angiofibroma* - **Angiofibromas** are benign vascular tumors; their treatment focuses on surgical resection, often with **preoperative embolization** to reduce bleeding. - **Mitomycin C** is not typically used for angiofibroma, as it does not address the vascular nature or growth pattern of this tumor effectively. *Skull base osteomyelitis* - **Skull base osteomyelitis** is an aggressive bacterial infection of the skull base, primarily treated with long-term **antibiotics** and sometimes surgical debridement. - **Mitomycin C**, an antineoplastic agent, has no role in treating bacterial infections of bone. *Tonsillectomy* - **Tonsillectomy** is a surgical procedure to remove the tonsils, usually performed for recurrent tonsillitis or sleep-disordered breathing. - **Mitomycin C** is not indicated for tonsillectomy; its use would not offer benefits and could potentially hinder wound healing or cause adverse effects.

Q: Which of the following statements about parotid tumors are correct? a) Pleomorphic adenoma is the most common variety b) Malignant disease is the most common variety c) Facial nerve involvement indicates malignancy d) Superficial parotidectomy is the treatment of choice

Only statements a, c, and d are correct. ***Only statements a, c, and d are correct*** - **Pleomorphic adenoma** is indeed the most common parotid tumor (60-70% of all parotid tumors) - **Facial nerve involvement** is a strong clinical indicator of malignancy, as benign tumors typically displace rather than invade the nerve - **Superficial parotidectomy** with facial nerve preservation is the standard surgical treatment for most parotid tumors - Statement b is false: approximately **80% of parotid tumors are benign**, with malignant tumors representing only ~20% *Only statements a and c are correct* - While this correctly identifies that pleomorphic adenoma is most common and facial nerve involvement suggests malignancy, it incorrectly excludes statement d - Superficial parotidectomy is indeed the standard treatment for most parotid tumors *All statements are correct* - This is incorrect because statement b is false - Malignant disease is NOT the most common variety; benign tumors (especially pleomorphic adenomas) predominate *Only statements b and d are correct* - This is incorrect because statement b is false - Malignant disease represents only ~20% of parotid tumors, not the most common variety

Q: Which intervention is best in patients operated for bilateral acoustic neuroma for hearing rehabilitation?

Auditory brainstem implant (ABI). ***Auditory brainstem implant (ABI)*** - Patients with bilateral acoustic neuromas often suffer damage to both **auditory nerves** during surgery, rendering cochlear implants ineffective. - The **ABI** bypasses the damaged auditory nerves and directly stimulates the **cochlear nucleus** in the brainstem, allowing for sound perception. *Bilateral cochlear implant* - This intervention is suitable when the **auditory nerve** remains intact and functional, which is typically not the case after bilateral acoustic neuroma surgery. - Cochlear implants depend on the integrity of the auditory nerve to transmit electrical signals to the brain. *Unilateral cochlear implant* - Similar to bilateral cochlear implants, a unilateral implant relies on a functional **auditory nerve** on the implanted side. - In bilateral acoustic neuroma, both auditory nerves are usually compromised or sacrificed, making a unilateral implant unsuitable for binaural hearing rehabilitation. *High power hearing aid* - Hearing aids only amplify sound and are effective for **sensorineural hearing loss** where the cochlea and auditory nerve are still functional. - They would not be beneficial in cases where the auditory nerve is damaged or absent, as occurs after bilateral acoustic neuroma removal.

Question 1

Which nerve needs to be carefully identified during parotid gland surgery?

Accepted Answer

Facial nerve

Answer

Trigeminal nerve

Answer

Greater petrosal nerve

Answer

Chorda tympani

Question 2

Nerve most commonly damaged in radical mastoidectomy is -

Accepted Answer

Facial

Answer

Cochlear

Answer

Vestibular

Answer

All of the options

Question 3

A patient with head and neck cancer has a contralateral lymph node of 3 cm size. What is the N staging?

Accepted Answer

N2c
Single or Multiple
Bilateral or Contralateral
None > 6 cm

Answer

N2a
Single
Ipsilateral
3 to 6 cm

Answer

N1
Single
Ipsilateral
Equal to or <3 cm

Answer

N3
Single or Multiple
Ipsilateral, Bilateral or Contralateral
Any node >6 cm

Question 4

Pell and Gregory classification includes all of the following except:

Accepted Answer

Root size.

Answer

Angulation of 3rd molar.

Answer

Height of mandible.

Answer

Relationship to adjacent teeth.

Question 5

Which of the following are stress bearing areas?

Accepted Answer

Slope of residual ridge, buccal shelf area and hard palate

Answer

Buccal shelf area, incisive papilla and palatine rugae

Answer

Slopes of residual ridge, palatine rugae and midpalatine raphe

Answer

Incisive papilla, slope of the residual ridge and crest of the residual ridge

Question 6

Lynch-Howarth surgery is for:

Accepted Answer

Sinonasal tumors

Answer

Otosclerosis

Answer

Nasal septal perforation

Answer

Acoustic neuroma

Question 7

What type of fracture of petrous temporal bone has the highest chance of facial nerve paralysis?

Accepted Answer

Transverse

Answer

All have equal incidence

Answer

Oblique

Answer

Longitudinal

Question 8

Topical mitomycin C is used to aid the following treatment:

Accepted Answer

Treatment of laryngotracheal stenosis

Answer

Endoscopic treatment of angiofibroma

Answer

Skull base osteomyelitis

Answer

Tonsillectomy

Question 9

Which of the following statements about parotid tumors are correct?
a) Pleomorphic adenoma is the most common variety
b) Malignant disease is the most common variety
c) Facial nerve involvement indicates malignancy
d) Superficial parotidectomy is the treatment of choice

Accepted Answer

Only statements a, c, and d are correct

Answer

Only statements a and c are correct

Answer

All statements are correct

Answer

Only statements b and d are correct

Question 10

Which intervention is best in patients operated for bilateral acoustic neuroma for hearing rehabilitation?

Accepted Answer

Auditory brainstem implant (ABI)

Answer

Bilateral cochlear implant

Answer

Unilateral cochlear implant

Answer

High power hearing aid

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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