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: Raccoon eye is a feature of:

Both Le Fort 2 and Le Fort 3. ***Both Le Fort 2 and Le Fort 3*** - **Raccoon eyes** (bilateral periorbital ecchymosis) is a hallmark sign of **midface fractures** that involve the base of the skull and orbital regions. - **Le Fort II fractures** (pyramidal fractures) involve the nasal bones, medial orbital walls, and infraorbital rims, with the fracture line extending through the ethmoid and lacrimal bones, allowing blood to extravasate into the periorbital area. - **Le Fort III fractures** (craniofacial dysjunction) cause complete separation of the midface from the skull base, resulting in extensive trauma that commonly produces raccoon eyes. - **Both fracture types** can cause this sign, making this the most complete answer. *Le Fort 3* - While Le Fort III fractures certainly cause **raccoon eyes** due to craniofacial dysjunction and skull base involvement, this option is **incomplete**. - Selecting only Le Fort III misses the fact that **Le Fort II fractures also cause raccoon eyes**, making "both" the better answer. *Le Fort 1* - **Le Fort I fractures** are horizontal fractures of the maxilla involving the palate and lower maxillary walls ("floating palate"). - These fractures **do not extend superiorly** to involve the orbital region or skull base, so they typically **do not cause raccoon eyes**. *Le Fort 2* - While Le Fort II fractures do cause **raccoon eyes** through involvement of the medial orbital walls, ethmoid, and lacrimal bones, this option is **incomplete**. - Selecting only Le Fort II misses the fact that **Le Fort III fractures also cause raccoon eyes**, making "both" the better answer.

Q: Removal of vertebral disc can be done by all these approaches except:

Laminoplasty. ***Laminoplasty*** - **Laminoplasty** is a procedure that *expands the spinal canal* by reshaping and repositioning the lamina, rather than removing it, to relieve pressure on the spinal cord. - Unlike disc removal techniques, it aims to *preserve the posterior spinal elements* and maintain spinal stability. *Hemilaminectomy* - A **hemilaminectomy** involves the *partial removal of a lamina on one side* of the vertebra. - This approach allows access to the spinal canal to remove disc material or decompress nerve roots. *Laminotomy* - **Laminotomy** is a procedure where a *small opening is made in the lamina* to access the spinal canal. - This minimal removal of bone is often sufficient for **microdiscectomy**, allowing for the removal of herniated disc fragments. *Laminectomy* - A **laminectomy** involves the *complete removal of the lamina* of one or more vertebrae. - This wider exposure is used for more extensive decompression, such as for **spinal stenosis** or larger disc herniations.

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: First lymph node involved in maxillary carcinoma:

Submandibular. ***Submandibular*** - Carcinomas of the **maxilla** drain primarily to the **submandibular lymph nodes (Level IB)** and **upper deep cervical (upper jugular) nodes (Level II)** as the first echelon lymph nodes. - The lymphatic drainage from the maxillary region follows vessels that communicate directly with the submandibular triangle and upper jugular chain. - These are considered the **primary drainage sites** for maxillary malignancies, with submandibular nodes being consistently involved in early lymphatic spread. *Lower jugular* - **Lower jugular lymph nodes (Level III-IV)** are part of the deep cervical chain but represent **secondary or tertiary drainage stations** for maxillary carcinoma. - They become involved in more advanced disease after the tumor has already metastasized to the upper echelon nodes (submandibular and upper jugular). - Lower jugular involvement typically indicates **progression of disease** rather than initial spread. *Submental* - **Submental lymph nodes** drain structures like the **chin**, **lower lip**, **anterior floor of mouth**, and tip of the tongue. - They are generally not involved in the lymphatic drainage pathway of maxillary carcinomas due to their distinct anatomical drainage territories. - Maxillary structures drain superolaterally, not toward the submental region. *Clavicular* - **Supraclavicular (clavicular) lymph nodes** represent **Level IV-V** nodes and indicate **advanced metastatic disease** in head and neck cancers. - Their involvement in maxillary carcinoma suggests extensive disease progression with skip metastases or sequential spread through multiple nodal levels. - These are never first echelon nodes for maxillary malignancies.

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: The preferred treatment of verrucous carcinoma of the larynx is:

Endoscopic removal. ***Endoscopic removal*** - Verrucous carcinoma is a **well-differentiated squamous cell carcinoma** with a **low metastatic potential**, making local control the primary goal. - **Endoscopic removal** (e.g., CO2 laser excision) allows for precise removal with good functional outcomes and is often curative for early-stage lesions. *Electron beam therapy* - While radiation can be used for laryngeal cancers, verrucous carcinoma has a **tendency to dedifferentiate (become more aggressive)** or develop **anaplastic transformation** after radiation therapy. - This can lead to a more aggressive, conventional squamous cell carcinoma with poorer prognosis, making it a less preferred primary treatment. *Total laryngectomy* - **Total laryngectomy** is a highly morbid procedure that involves the complete removal of the larynx. - It is reserved for extensive, deeply infiltrative tumors or cases where other treatments have failed, which is typically not the case for most verrucous carcinomas. *Partial laryngectomy* - **Partial laryngectomy** involves removing part of the larynx, aiming to preserve voice and swallowing function. - This is an option for certain laryngeal cancers, but for verrucous carcinoma, less invasive endoscopic removal is often sufficient and preferred given its non-invasive nature.

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.

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

Raccoon eye is a feature of:

Accepted Answer

Both Le Fort 2 and Le Fort 3

Answer

Le Fort 3

Answer

Le Fort 1

Answer

Le Fort 2

Question 3

Removal of vertebral disc can be done by all these approaches except:

Accepted Answer

Laminoplasty

Answer

Hemilaminectomy

Answer

Laminotomy

Answer

Laminectomy

Question 4

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 5

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 6

First lymph node involved in maxillary carcinoma:

Accepted Answer

Submandibular

Answer

Lower jugular

Answer

Submental

Answer

Clavicular

Question 7

Sistrunk operation is for:

Accepted Answer

Thyroglossal cyst

Answer

Thyroglossal fistula

Answer

Branchial fistula

Answer

Branchial cyst

Question 8

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 9

The preferred treatment of verrucous carcinoma of the larynx is:

Accepted Answer

Endoscopic removal

Answer

Electron beam therapy

Answer

Total laryngectomy

Answer

Partial laryngectomy

Question 10

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

Accepted Answer

Surgery and Radiotherapy

Answer

Radiotherapy alone

Answer

Chemoradiation

Answer

Surgery alone

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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