Head and Neck Surgery Practice Questions

Q: Which of the following statements about thyroglossal cyst is NOT true?

Does not move with deglutition. ***Does not move with deglutition*** - A **thyroglossal cyst** is connected to the **foramen cecum** at the base of the tongue via a remnant of the thyroglossal duct, which **moves superiorly with both tongue protrusion and deglutition** due to its attachment to the hyoid bone. - The statement that it does not move with deglutition is therefore **incorrect**. *Moves with protrusion of tongue* - This statement is **true** because the **thyroglossal duct** is embryologically continuous with the tongue's base at the foramen cecum. - When the tongue is protruded, this connection pulls the cyst **upwards**. *Sistrunk's operation is the treatment of choice* - This statement is **true** because **Sistrunk's operation** involves removing the cyst along with the central portion of the **hyoid bone** and a core of tissue from the path to the foramen cecum. - This extensive removal is crucial to prevent recurrence, as simple excision often leaves remnants of the duct. *Most common site is subhyoid region* - This statement is **true** as approximately 60-65% of **thyroglossal cysts** are located in the **subhyoid region**, just below the hyoid bone. - Other common locations include suprahyoid and at the level of the thyrohyoid membrane.

Q: Treatment of non-displaced sagittal condylar fracture?

Reduction for two weeks and elastic guided jaw movements. ***Reduction for two weeks and elastic guided jaw movements*** - This approach aims for **closed reduction** with **minimal immobilization**, promoting early mobilization to prevent **ankylosis** and foster optimal healing. - **Elastic guided jaw movements** help restore function and prevent stiffness during the critical healing phase, aligning with current best practices for condylar fractures. *No treatment* - Leaving a condylar fracture untreated can lead to **malocclusion**, **TMJ dysfunction**, chronic pain, and **facial asymmetry**. - **Condylar fractures** require intervention to ensure proper healing and restoration of mandibular function. *ORIF* - **Open reduction and internal fixation (ORIF)** is generally reserved for displaced condylar fractures, particularly those that cause significant **malocclusion**, cannot be managed by closed reduction, or involve dislocation of the condyle from the fossa. - While ORIF provides rigid fixation, it carries risks such as **facial nerve injury** and **scarring**, and is not the first-line treatment for all condylar fractures. *Reduction for four weeks + physiotherapy* - **Prolonged immobilization** for four weeks can lead to **joint stiffness**, **muscle atrophy**, and **ankylosis** of the temporomandibular joint (TMJ). - While physiotherapy is essential, it should be initiated earlier and combined with shorter periods of reduction to promote **early functional recovery**.

Q: All of the following statements regarding stones in the submandibular gland are true except one:

Majority of submandibular stones are radiolucent. ***Majority of submandibular stones are radiolucent*** - This statement is **incorrect** because submandibular stones (sialoliths) are typically composed of **calcium phosphate and calcium carbonate**, making them **radiopaque** on plain radiographs. - Approximately **80-90%** of submandibular stones are radiopaque and visible on X-rays. - Only 10-20% are radiolucent, making this the false statement in this "except" question. *80% of stones occur in the submandibular gland* - This statement is **true**; the submandibular gland is the most common site for salivary stones, accounting for **80-92%** of all sialoliths. - This high prevalence is due to Wharton's duct being longer and more tortuous, gravity-dependent positioning, and the alkaline mucinous nature of submandibular saliva. *Patient presents with acute pain and swelling in the region of the submandibular gland* - This is **true** and represents the classic presentation of sialolithiasis. - Pain and swelling typically **worsen with eating** (when salivary flow increases) and may partially subside between meals. - This is often called "mealtime syndrome" or prandial pain. *The hypoglossal nerve is at risk during submandibular gland excision* - This statement is **true**. During submandibular gland excision, the **hypoglossal nerve (CN XII)** runs close to the superior aspect of the gland and can be injured. - Other nerves at risk include the **marginal mandibular branch of the facial nerve** (most commonly injured, causing lower lip weakness) and the **lingual nerve** (causing tongue numbness). - Hypoglossal nerve injury results in tongue deviation toward the affected side and difficulties with speech and swallowing.

Q: Infection of the submandibular space is seen in:

Ludwig angina. ***Ludwig angina*** - This is a rapidly progressive and potentially life-threatening **cellulitis** of the **submandibular, sublingual, and submental spaces**. - It typically originates from an **infected mandibular molar tooth** (most commonly the 2nd or 3rd molar). - Characterized by **bilateral** involvement, **brawny induration** of the neck, and potential for **airway compromise**. *Prinzmetal angina* - This is a type of **angina pectoris** characterized by chest pain due to **coronary artery spasm**, unrelated to infection. - It primarily affects the **heart** and does not involve the submandibular space. *Unstable angina* - This refers to **chest pain** or discomfort that occurs at rest or with minimal exertion, indicating a **pre-infarction state** due to coronary artery disease. - It is a cardiac condition and has no association with head and neck infections. *Vincent angina* - This condition is also known as **acute necrotizing ulcerative gingivitis (ANUG)** or trench mouth, a severe infection of the **gums and oral mucosa**. - While it is an infection of the oral cavity, it primarily affects the **gingiva** and does not involve the deep submandibular space in the same way as Ludwig angina.

Q: High tracheostomy is done in which one of the following conditions?

Tracheal stenosis. ***Tracheal stenosis*** - A **high tracheostomy** is performed when there is **lower tracheal stenosis** or obstruction, requiring placement of the tracheostomy stoma **above the stenotic segment**. - This approach ensures that the **tracheostomy tube** bypasses the narrowed portion of the trachea and provides a patent airway. - The level of tracheostomy is chosen based on the location of the pathology - high tracheostomy for lower pathology, and vice versa. *Laryngeal cancer* - In **laryngeal cancer**, a **low tracheostomy** is typically preferred, not a high one. - A high tracheostomy in laryngeal malignancy is generally **contraindicated** due to the risk of tumor seeding and interference with surgical planning. - The tracheostomy should be placed **away from the tumor site** and below the pathology, especially if laryngectomy is planned. *Severe asthma exacerbation* - **Severe asthma exacerbation** rarely requires a tracheostomy; endotracheal intubation and mechanical ventilation are the standard initial management. - If prolonged ventilatory support is needed, a **standard tracheostomy** (not high) would be performed. - There is no specific indication for high tracheostomy placement in asthma. *Vocal cord dysfunction* - **Vocal cord dysfunction (VCD)** involves paradoxical vocal cord movement and is typically managed with **conservative measures** including speech therapy and breathing exercises. - VCD does not cause structural obstruction requiring surgical airway intervention. - Tracheostomy, especially high tracheostomy, has no role in the management of VCD.

Q: What is the purpose of tilting the cast during surveying?

Obtain a favorable path of insertion. ***Obtain a favorable path of insertion*** - Tilting the cast allows the dental professional to analyze the various **undercuts** and **interferences** on the teeth and surrounding tissues. - By adjusting the cast's orientation, an **optimal path of insertion** can be identified, minimizing interferences and ensuring the proper seating of a dental prosthesis. *Achieve maximum guiding planes* - While guiding planes are important for stability and resistance to displacement, the primary purpose of cast tilting is not to maximize them directly. - **Guiding planes** are prepared on the teeth to create parallel surfaces, which are then evaluated and utilized after the optimal path of insertion is determined. *Create undercuts* - The purpose of tilting is to identify and utilize existing **undercuts** for retention, not to create them. - **Undercuts** are naturally present areas below the height of contour, and tilting helps in selecting the most appropriate ones for clasp engagement. *Obtain retention* - While tilting the cast ultimately contributes to effective **retention** by identifying suitable undercuts, it is part of the broader goal of establishing a functional path of insertion. - **Retention** is achieved by the engagement of retentive clasps into specific undercuts that are identified during the surveying process, after determining the path of insertion.

Q: Which of the following swellings moves on protrusion of the tongue?

Thyroglossal cyst. ***Thyroglossal cyst*** - A **thyroglossal cyst** is a remnant of the **thyroglossal duct**, which connects the thyroid gland to the tongue during embryonic development. - Due to its embryological connection with the foramen cecum at the base of the tongue, it moves **superiorly with tongue protrusion** and swallowing. *Branchial cyst* - A **branchial cyst** is a congenital anomaly resulting from the incomplete obliteration of branchial arches, typically presenting laterally in the neck. - It does not have an anatomical connection to the tongue and therefore **does not move with tongue protrusion**. *Ranula* - A **ranula** is a mucocele found on the floor of the mouth, usually caused by obstruction or rupture of a salivary gland duct. - It is located entirely within the oral cavity or submandibular space and **does not move with tongue protrusion**. *Cyst in hyoid bone* - A cyst within the **hyoid bone** itself is exceedingly rare; more commonly, a thyroglossal cyst can be intimately associated with or pass through the hyoid bone. - A cyst within the bone structure would generally not exhibit mobility with tongue protrusion.

Q: Which of the following is a midline neck swelling?

Thyroglossal cyst. ***Thyroglossal cyst*** - A thyroglossal cyst is a congenital anomaly arising from the **remnant of the thyroglossal duct**, which is the embryonic path of the thyroid gland's descent. - It characteristically presents as a **midline neck swelling**, often just below the hyoid bone, and typically **moves upwards with tongue protrusion**. *Carotid body tumor* - A carotid body tumor, or **chemodectoma**, is usually located in the **lateral neck**, specifically at the carotid bifurcation. - It is typically **pulsatile** and has a characteristic **bruit**, with limited mobility in the horizontal but not vertical plane (Fontaine's sign). *Branchial cyst* - A branchial cyst is a congenital lesion that typically presents in the **lateral neck**, usually anterior to the sternocleidomastoid muscle. - It arises from **incomplete obliteration of the branchial arches** during embryonic development. *Cystic hygroma* - A cystic hygroma is a **lymphatic malformation** that commonly presents as a **soft, compressible mass** in the **posterolateral neck**. - These are typically **transilluminable** and can be quite large, often visible at birth or in early childhood.

Q: Tracheostomy is typically performed between which tracheal rings?

2nd-3rd tracheal rings. ***2nd-3rd tracheal rings*** - The space between the **2nd and 3rd tracheal rings** is the **most common and preferred site** for performing a tracheostomy. - This location provides optimal balance between ease of access and safety, minimizing risk of damage to the **cricoid cartilage** superiorly while avoiding larger vascular structures inferiorly. - This standard placement reduces complications including subglottic stenosis and major vessel injury. - Most surgical textbooks and guidelines recommend this as the **ideal anatomical site** for elective tracheostomy. *1st tracheal ring* - Performing a tracheostomy at the level of the **first tracheal ring** is generally avoided as it is too high and carries significant risk of damaging the **cricoid cartilage** and affecting the **larynx**. - This high placement can lead to **subglottic stenosis** and voice complications. *5th-6th tracheal rings* - A tracheostomy performed between the **5th and 6th tracheal rings** is considered too low and increases the risk of complications. - This deep approach may encounter surrounding vascular structures and is generally not recommended for standard tracheostomy procedures. *7th-8th tracheal rings* - Performing a tracheostomy between the **7th and 8th tracheal rings** is too low and increases the risk of entering the **mediastinum** or damaging the **innominate artery** or other major vessels. - This deeper dissection can lead to significant bleeding and other serious complications.

Q: Which of the following is not a boundary of Jackson's triangle used in tracheotomy?

Outer border of sternocleidomastoid. ***Outer border of sternocleidomastoid*** - Jackson's triangle, or the **surgical safety triangle for tracheotomy**, is defined by the **upper border of the sternal manubrium (suprasternal notch)**, the **lower border of the thyroid cartilage**, and the **medial borders of the sternocleidomastoid muscles**. - The **outer border of the sternocleidomastoid** muscle is not one of the boundaries of this specific surgical triangle. *Suprasternal notch* - The **suprasternal notch** (upper border of the sternal manubrium) forms the **inferior boundary** of Jackson's triangle. - This anatomical landmark is crucial for correctly identifying the cricoid cartilage and trachea for a safe tracheotomy. *Lower edge thyroid cartilage* - The **lower edge of the thyroid cartilage** forms the **superior boundary** of Jackson's triangle. - Palpation of this structure helps to locate the cricoid cartilage and the tracheal rings below it. *Inner border of sternocleidomastoid* - The **inner (medial) borders of the sternocleidomastoid muscles** form the two **lateral boundaries** of Jackson's triangle. - These muscles delineate the central neck region where the trachea is accessed during a tracheotomy.

Question 1

Which of the following statements about thyroglossal cyst is NOT true?

Accepted Answer

Does not move with deglutition

Answer

Sistrunk's operation is the treatment of choice

Answer

Most common site is subhyoid region

Answer

Moves with protrusion of tongue

Question 2

Treatment of non-displaced sagittal condylar fracture?

Accepted Answer

Reduction for two weeks and elastic guided jaw movements

Answer

ORIF

Answer

No treatment

Answer

Reduction for four weeks + physiotherapy

Question 3

All of the following statements regarding stones in the submandibular gland are true except one:

Accepted Answer

Majority of submandibular stones are radiolucent

Answer

Patient presents with acute pain and swelling in the region of the submandibular gland

Answer

80% of stones occur in the submandibular gland

Answer

The hypoglossal nerve is at risk during submandibular gland excision

Question 4

Infection of the submandibular space is seen in:

Accepted Answer

Ludwig angina

Answer

Prinzmetal angina

Answer

Unstable angina

Answer

Vincent angina

Question 5

High tracheostomy is done in which one of the following conditions?

Accepted Answer

Tracheal stenosis

Answer

Laryngeal cancer

Answer

Severe asthma exacerbation

Answer

Vocal cord dysfunction

Question 6

What is the purpose of tilting the cast during surveying?

Accepted Answer

Obtain a favorable path of insertion

Answer

Achieve maximum guiding planes

Answer

Create undercuts

Answer

Obtain retention

Question 7

Which of the following swellings moves on protrusion of the tongue?

Accepted Answer

Thyroglossal cyst

Answer

Branchial cyst

Answer

Ranula

Answer

Cyst in hyoid bone

Question 8

Which of the following is a midline neck swelling?

Accepted Answer

Thyroglossal cyst

Answer

Carotid body tumor

Answer

Branchial cyst

Answer

Cystic hygroma

Question 9

Tracheostomy is typically performed between which tracheal rings?

Accepted Answer

2nd-3rd tracheal rings

Answer

7th-8th tracheal rings

Answer

5th-6th tracheal rings

Answer

1st tracheal ring

Question 10

Which of the following is not a boundary of Jackson's triangle used in tracheotomy?

Accepted Answer

Outer border of sternocleidomastoid

Answer

Suprasternal notch

Answer

Lower edge thyroid cartilage

Answer

Inner border of sternocleidomastoid

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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