Head and Neck Surgery Practice Questions

Q: Second primary tumor of head and neck is most commonly seen in malignancy of:

Oral cavity. ***Oral cavity*** - Patients with **oral cavity squamous cell carcinoma** (OCSCC) have the highest incidence of developing **second primary tumors** (SPTs) in the head and neck region, often due to shared risk factors like tobacco and alcohol use. - The concept of "**field cancerization**" explains this phenomenon, where prolonged exposure to carcinogens leads to widespread genetic alterations in the mucosal lining, predisposing multiple sites to develop independent primary cancers. *Paranasal sinuses* - While paranasal sinus cancers can be aggressive, they are less commonly associated with the development of **second primary tumors** within the head and neck compared to oral cavity cancers. - The etiology of paranasal sinus cancers is often linked to specific exposures like wood dust or nickel, which are less broadly distributed across the upper aerodigestive tract compared to tobacco and alcohol. *Hypopharynx* - Hypopharyngeal cancers do carry a significant risk of developing **second primary tumors**, particularly in the esophagus and lungs, but the overall incidence of head and neck SPTs is generally considered lower than that for oral cavity cancers. - The anatomical location and typical lymphatic drainage patterns of hypopharyngeal cancers might direct SPTs to different sites compared to oral cavity cancers. *Larynx* - Laryngeal cancers, especially those of the **glottis**, are also strongly associated with tobacco and alcohol. However, the incidence of **second primary tumors** in other head and neck sites is typically reported to be lower than in oral cavity cancer patients. - While laryngeal cancer patients are at risk for SPTs in the lung and esophagus, the synchronous or metachronous development of another primary tumor *within* the head and neck region is more prevalent in oral cavity cases.

Q: Weber-Ferguson approach is used for?

Maxillectomy. ***Maxillectomy*** - The **Weber-Ferguson approach**, also known as the **lateral rhinotomy approach**, is a standard surgical incision used to access the midface, particularly for procedures involving the maxilla. - It provides excellent exposure for **maxillectomy**, which is the surgical removal of part or all of the maxilla, often performed for tumors of the maxillary sinus or hard palate. *Mastoidectomy* - This procedure involves the surgical removal of diseased mastoid air cells, typically performed for chronic otitis media or cholesteatoma. - The surgical approaches for mastoidectomy usually involve incisions behind the ear (**postauricular** or **endaural**), not the Weber-Ferguson incision. *Myringoplasty* - Myringoplasty is a surgical repair of a perforated eardrum (tympanic membrane). - This procedure is typically performed through the ear canal (**transcanal approach**) or a small incision behind the ear, and does not require a large facial incision like the Weber-Ferguson. *Mandibulectomy* - Mandibulectomy involves the surgical removal of part or all of the mandible (jawbone), often for malignant tumors. - Approaches for mandibulectomy typically involve **transoral**, **submandibular**, or **lip-splitting incisions**, which are distinct from the Weber-Ferguson approach and designed for lower facial access.

Q: All are true about tracheostomy tube except -

Removal of metallic tube in every 2-3 days. ***Removal of metallic tube in every 2-3 days*** - This statement is **false**. Metallic tracheostomy tubes, particularly Jackson tubes, are designed for **long-term placement** and typically remain in situ for extended periods (weeks to months). - The inner cannula is removed regularly for cleaning, but the outer metallic tube itself is not removed every 2-3 days as this would cause unnecessary trauma to the stoma. - Regular cleaning of the inner cannula maintains airway hygiene without disturbing the outer tube. *Made up of silver or stainless steel* - This statement is **true**. Traditional Jackson tracheostomy tubes are made of **silver**, which provides excellent durability, biocompatibility, and antimicrobial properties. - Modern metallic tubes may also be made of **stainless steel**, which can be sterilized and reused. - These materials have smooth surfaces that minimize tissue irritation and allow for long-term use. *Jackson's tube has 2 lumens* - This statement is **true**. Jackson tracheostomy tubes have a **double lumen design** consisting of an outer cannula that remains in the stoma and an **inner cannula** that can be removed for cleaning. - This design allows for maintenance of airway hygiene without disturbing the outer cannula, reducing the risk of accidental decannulation and stoma trauma. *Cuffed tube is used to prevent aspiration of pharyngeal secretion* - This statement is **true**. **Cuffed tracheostomy tubes** have an inflatable cuff that creates a seal in the trachea, primarily to **prevent aspiration** of oropharyngeal secretions and gastric contents into the lower respiratory tract. - The cuff also ensures effective positive pressure ventilation by preventing air leakage around the tube during mechanical ventilation.

Q: A glomus tumor extending to involve the carotid canal is classified as:

Type CI. ***Type CI*** - The **Fisch classification system** for **glomus jugulare tumors** defines Type C1 as tumors involving the **vertical portion of the carotid canal**. - Type C tumors extend into the infralabyrinthine compartment of the temporal bone and involve the petrous apex. - C1 specifically indicates involvement of the carotid canal, representing a higher extent of disease and often requiring more complex surgical approaches due to the involvement of critical neurovascular structures. *Type C2* - In the Fisch classification, Type C2 refers to **glomus tumors** involving both the **vertical and horizontal portions of the carotid canal**. - This represents more extensive involvement than C1 but does not primarily denote carotid canal involvement as the defining characteristic asked in the question. *Type B* - This classification in the Fisch system describes **glomus tympanicum tumors** limited to the **tympanomastoid area** without involvement of the infralabyrinthine compartment. - It does not apply to tumors extending into the carotid canal. *Type C3* - In the Fisch classification, Type C3 refers to **glomus tumors** that invade the **horizontal (intrapetrous) portion of the carotid canal**. - While it also involves the carotid canal, C1 is the most appropriate answer as it specifically denotes initial carotid canal involvement.

Q: The walls of the orbit which are removed in the two wall decompression for proptosis of thyroid ophthalmopathy include:

Orbital floor and medial wall. ***Orbital floor and medial wall*** - The **orbital floor** and **medial wall** are the most commonly removed walls in a two-wall decompression for **thyroid ophthalmopathy** because they provide significant space for orbital tissue expansion. - This combination allows for reduction of **proptosis** and decompression of the optic nerve while minimizing the risk of adverse visual outcomes. *Medial and lateral walls* - While both the medial and lateral walls can be removed, removing only these two would provide less effective decompression compared to including the orbital floor, especially for severe proptosis. - Removing the lateral wall involves working closer to the **lacrimal gland** and may have different surgical risks compared to the floor. *Orbital floor and lateral wall* - Removing the orbital floor and lateral wall typically leads to less effective decompression for **proptosis** compared to including the medial wall, which is often severely affected by muscle swelling in thyroid eye disease. - Accessing the lateral wall and floor together can be more complex without the simultaneous removal of the medial wall. *Orbital roof and medial wall* - The **orbital roof** is generally not a primary target for two-wall decompression in thyroid ophthalmopathy as it carries a higher risk of complications related to the **cranial cavity** and provides less space for orbital contents compared to the floor and medial wall. - Decompressing the roof is usually reserved for very specific, severe cases where other approaches have failed, or for superior compartment pathology.

Q: Trotter's triad is seen in carcinoma of -

Nasopharynx. ***Nasopharynx*** - **Trotter's triad** is a classic presentation of **nasopharyngeal carcinoma**, especially when the tumor involves the fossa of Rosenmüller. - The triad consists of **unilateral conductive deafness** (due to Eustachian tube obstruction), **trigeminal neuralgia** (due to tumor involvement of the gasserian ganglion), and **soft palate paralysis**. *Larynx* - Laryngeal carcinoma typically presents with **hoarseness**, **dysphagia**, and **stridor**, not the specific triad described. - While it can involve cranial nerves, the characteristic combination of symptoms in Trotter's triad is not seen. *Ethmoid sinus* - Carcinoma of the ethmoid sinus usually causes symptoms like **nasal obstruction**, **epistaxis**, and **proptosis** if it extends into the orbit. - It does not typically present with conductive deafness, trigeminal neuralgia, or soft palate paralysis. *Maxilla* - Maxillary carcinoma often presents with **facial swelling**, **pain**, **nasal obstruction**, and dental symptoms. - While it can invade adjacent structures, Trotter's triad is not a typical presentation for this type of cancer.

Q: Tonsillectomy is typically indicated after how many episodes of quinsy (peritonsillar abscess)?

2. ***2*** - For recurrent quinsy (peritonsillar abscess), **tonsillectomy** is generally considered after **two documented episodes** to prevent further recurrences. - This recommendation is based on the increased likelihood of recurrence after a second episode, weighed against the risks and benefits of surgery. *12* - Waiting for 12 episodes of quinsy before considering tonsillectomy is **excessive** and would subject the patient to undue pain, discomfort, and potential complications from multiple infections. - Current guidelines recommend intervention much sooner for recurrent cases to improve patient quality of life and prevent severe outcomes. *4* - While 4 episodes might be considered in some contexts for recurrent tonsillitis, for **recurrent quinsy**, the threshold for tonsillectomy is typically lower due to the more severe nature and potential complications of abscess formation. - Four episodes would be an unnecessarily prolonged delay for a patient experiencing multiple peritonsillar abscesses. *6* - Similar to 4 episodes, 6 episodes of quinsy before tonsillectomy is **not standard practice** as it exceeds the typically recommended intervention threshold. - Prolonged recurrence of quinsy increases the risk of airway obstruction, deep neck space infection, and other serious complications.

Q: The position adopted for tonsillectomy is also adopted for this procedure.

Tracheostomy. ***Tracheostomy*** - For a **tracheostomy**, the patient is typically positioned supine with the neck extended (often with a shoulder roll) to expose the trachea, similar to the Rose position used for tonsillectomy. - This position optimizes surgical access to the neck and upper airway, allowing for safe incision and tube placement. *Indirect laryngoscopy* - This procedure usually involves the patient sitting upright with the neck slightly flexed and the head extended, using a mirror to visualize the larynx. - It specifically avoids surgical intervention and thus does not require the same deep neck extension as tonsillectomy or tracheostomy. *Bronchoscopy* - While patient positioning may vary, bronchoscopy is primarily an endoscopic procedure that involves inserting a bronchoscope through the mouth or nose into the airways. - It does not require a surgical approach to the anterior neck and therefore does not use the tonsillectomy position. *Direct laryngoscopy* - Though it provides a direct view of the larynx, the patient is usually supine with the head extended (sniffing position) to align the oral, pharyngeal, and laryngeal axes. - While there is some neck extension, it differs from the more pronounced extension used for direct surgical access to the neck, as in tracheostomy or tonsillectomy.

Q: What is the most appropriate treatment after resection of lateral border of tongue carcinoma with high-risk features (positive margins, perineural invasion)?

Adjuvant radiotherapy. ***Adjuvant radiotherapy*** - **Adjuvant radiotherapy** is the **standard of care** after surgical resection of **oral tongue squamous cell carcinoma** with **high-risk features** such as: - **Positive or close margins** ( 4 mm depth) - **Advanced T stage** (T3-T4) - These features significantly **increase the risk of local recurrence**, and adjuvant radiotherapy improves **locoregional control** and **overall survival**. - The **tongue** has rich lymphatic drainage making it prone to both local recurrence and regional metastasis, necessitating adjuvant therapy. *Systemic chemotherapy* - **Systemic chemotherapy alone** is not used as adjuvant treatment after resection of oral tongue carcinoma. - It may be combined with radiotherapy (**concurrent chemoradiotherapy**) in cases with **extranodal extension** or multiple positive nodes, but standalone chemotherapy is reserved for **palliative treatment** of distant metastatic disease. *Surgical neck dissection* - **Neck dissection** is typically performed **at the same time** as primary tumor resection (concurrent procedure), not as a separate "after treatment." - It addresses **regional lymph node metastasis** rather than controlling the primary tumor site. - If not done initially and nodes become clinically positive later, it would be therapeutic neck dissection, but this is not routine adjuvant therapy. *Postoperative observation* - **Observation alone** is appropriate only for **very early-stage disease** (T1N0) with **clear margins** (>5 mm), **no depth invasion** (<4 mm), and **absence of adverse features** like PNI or LVI. - Given the presence of **high-risk features** in this scenario, observation would result in unacceptably high rates of **local recurrence**.

Q: Which of the following is NOT a surgical landmark for parotid surgery?

Inferior belly of omohyoid. ***Inferior belly of omohyoid*** - The **inferior belly of the omohyoid** muscle is located in the anterior triangle of the neck and is not anatomically relevant to parotid gland surgery. - Its position is too medial and inferior to serve as a reliable landmark for the facial nerve or the parotid gland itself. *Tragal pointer* - The **tragal pointer** is a crucial and easily palpable landmark for locating the main trunk of the facial nerve during parotidectomy. - The facial nerve typically emerges approximately 1 cm deep and inferior to the tragal pointer. *Digastric posterior belly* - The **posterior belly of the digastric muscle** courses anteriorly and inferiorly to the entry point of the facial nerve into the parotid gland. - Following this muscle provides a reliable anatomical guide to identify the facial nerve, as the nerve often crosses superficial to it. *Stylomastoid foramen* - The **stylomastoid foramen** is the exit point of the facial nerve from the skull, located between the styloid and mastoid processes. - Identifying this foramen allows for direct localization of the facial nerve trunk as it emerges to enter the parotid gland.

Question 1

Second primary tumor of head and neck is most commonly seen in malignancy of:

Accepted Answer

Oral cavity

Answer

Paranasal sinuses

Answer

Hypopharynx

Answer

Larynx

Question 2

Weber-Ferguson approach is used for?

Accepted Answer

Maxillectomy

Answer

Mastoidectomy

Answer

Myringoplasty

Answer

Mandibulectomy

Question 3

All are true about tracheostomy tube except -

Accepted Answer

Removal of metallic tube in every 2-3 days

Answer

Jackson's tube has 2 lumens

Answer

Cuffed tube is used to prevent aspiration of pharyngeal secretion

Answer

Made up of silver or stainless steel

Question 4

A glomus tumor extending to involve the carotid canal is classified as:

Accepted Answer

Type CI

Answer

Type C2

Answer

Type B

Answer

Type C3

Question 5

The walls of the orbit which are removed in the two wall decompression for proptosis of thyroid ophthalmopathy include:

Accepted Answer

Orbital floor and medial wall

Answer

Medial and lateral walls

Answer

Orbital floor and lateral wall

Answer

Orbital roof and medial wall

Question 6

Trotter's triad is seen in carcinoma of -

Accepted Answer

Nasopharynx

Answer

Larynx

Answer

Ethmoid sinus

Answer

Maxilla

Question 7

Tonsillectomy is typically indicated after how many episodes of quinsy (peritonsillar abscess)?

Accepted Answer

2

Answer

12

Answer

4

Answer

6

Question 8

The position adopted for tonsillectomy is also adopted for this procedure.

Accepted Answer

Tracheostomy

Answer

Indirect laryngoscopy

Answer

Bronchoscopy

Answer

Direct laryngoscopy

Question 9

What is the most appropriate treatment after resection of lateral border of tongue carcinoma with high-risk features (positive margins, perineural invasion)?

Accepted Answer

Adjuvant radiotherapy

Answer

Systemic chemotherapy

Answer

Surgical neck dissection

Answer

Postoperative observation

Question 10

Which of the following is NOT a surgical landmark for parotid surgery?

Accepted Answer

Inferior belly of omohyoid

Answer

Tragal pointer

Answer

Digastric posterior belly

Answer

Stylomastoid foramen

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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