Head and Neck Surgery Practice Questions

Q: Treatment of choice for angiofibroma -

Surgery. ***Surgery*** - **Surgical excision** is considered the **gold standard** and primary treatment for **nasopharyngeal angiofibroma**, especially for localized and resectable tumors. - Complete removal aims to prevent tumor recurrence and alleviate symptoms like **epistaxis** and **nasal obstruction**. *Radiotherapy* - **Radiotherapy** is generally reserved for **recurrent** or **unresectable tumors**, or cases with **intracranial extension**. - It carries risks of side effects such as **growth retardation** and **secondary malignancies**, making it less favorable as a first-line treatment. *Combination of treatments (Surgery and Radiotherapy)* - A **combination** approach is typically utilized for **advanced-stage tumors** where complete surgical resection is challenging, or in cases of recurrence. - It is not the initial treatment for most angiofibromas, which often respond well to surgery alone. *Chemotherapy* - **Chemotherapy** has **limited efficacy** in the treatment of angiofibroma due to the tumor's benign nature and its primary vascular composition. - It is rarely used, even in recurrent or advanced cases, as other modalities like surgery or radiotherapy are more effective.

Q: Which cancers can cause referred otalgia (referred pain in the ear)? Select the most comprehensive answer.

Cancer of the pharynx, oral cavity, and larynx. ***Cancer of the pharynx, oral cavity, and larynx*** - Cancers in these locations can cause **referred otalgia** due to shared innervation of the ear by cranial nerves that also supply these areas. - Specifically, the **glossopharyngeal nerve (IX)**, **vagus nerve (X)**, and **trigeminal nerve (V3)** are involved in both sensation from these head and neck regions and the ear. *Cancer of the pharynx* - While pharyngeal cancer can cause **referred otalgia** through cranial nerves IX and X, it is not the most comprehensive answer as other sites are also involved. - This option exclusively mentions the pharynx, missing other important anatomical locations that can also refer pain to the ear. *Cancer of the oral cavity* - Cancer here can cause **referred otalgia**, primarily through the **trigeminal nerve (V3)**, which innervates parts of the oral cavity and the ear. - However, similar to pharyngeal cancer, this option is not comprehensive as it omits other regions related to referred ear pain. *Cancer of the larynx* - Laryngeal cancer can cause **referred otalgia** via the **vagus nerve (X)**, specifically its superior laryngeal branch. - This option is also incomplete as it does not include cancers of the pharynx or oral cavity, which are equally important causes of referred ear pain.

Q: True about carotid body tumor is all except:

First-bite syndrome is a known complication. ***Correct Answer: First-bite syndrome is NOT a known complication*** - **First-bite syndrome** is classically associated with **parotid gland surgery**, not carotid body tumor surgery - It occurs due to **sympathetic denervation** following parotid surgery, causing severe pain with the first bite of each meal - Carotid body tumor surgery has different complications: **cranial nerve injuries** (vagus, hypoglossal, glossopharyngeal), **vascular injury**, and **stroke** - This is the EXCEPTION - it is NOT true about carotid body tumors *Hereditary predisposition - TRUE* - **10-35% of carotid body tumors** have a familial/hereditary pattern - Associated with mutations in **succinate dehydrogenase (SDH) genes** (SDH-B, SDH-C, SDH-D) - Hereditary cases tend to be **bilateral** and present at a younger age - While most are sporadic, hereditary predisposition is a well-recognized feature *Lyre sign on angiography - TRUE* - The **"lyre sign"** is a classic angiographic finding - Represents **splaying of the carotid bifurcation** as the tumor grows between the internal and external carotid arteries - This widening of the carotid angle resembles the shape of a lyre (ancient musical instrument) - Highly characteristic of carotid body tumors *Benign - TRUE* - Carotid body tumors are typically **benign paragangliomas** - Slow-growing and usually do not metastasize - Only **5-10% are malignant** with metastatic potential - However, they can be locally aggressive and cause complications due to their location

Q: A high tracheostomy may be indicated in:

Severe bilateral vocal cord paralysis. ***Severe bilateral vocal cord paralysis*** - **High tracheostomy** may be indicated in severe bilateral vocal cord paralysis, particularly when both cords are paralyzed in the **median (adducted) position**, causing critical airway obstruction. - A high tracheostomy is performed at the level of the **2nd or 3rd tracheal ring**, closer to the site of obstruction at the glottic level, providing immediate airway access. - This can serve as temporary relief while definitive treatments like **arytenoidectomy, cordectomy, or vocal cord lateralization** are planned. - In emergency situations, high tracheostomy or cricothyroidotomy may be life-saving. *Advanced carcinoma of the larynx* - High tracheostomy is **contraindicated** in laryngeal carcinoma as it may: - Transect through tumor tissue - Cause tumor seeding in the tracheal stoma - Compromise subsequent **total laryngectomy** procedures - **Low tracheostomy** (below the tumor, at 4th-5th tracheal ring) is the standard approach to secure the airway while avoiding tumor interference. *Chronic scleroma involving the larynx* - Scleroma typically causes **subglottic stenosis** and involves extensive tracheal disease. - **Low tracheostomy** is preferred to bypass the diseased area completely. - A high tracheostomy would be too close to the pathological process, risking inadequate airway and complications. *Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)* - Tracheostomy is generally **avoided** in RRP due to the significant risk of **seeding papillomas** into the tracheal stoma and lower airways. - Management focuses on **repeated endoscopic laser ablation** or surgical excision to preserve laryngeal function. - If tracheostomy is absolutely necessary, meticulous technique and close follow-up are required.

Q: Which of the following surgeries is contraindicated below 12 years of age?

SMR. ***SMR (Submucous Resection of the septum)*** - SMR procedure involves removing a significant portion of the **septal cartilage and bone**, which is crucial for nasal growth. - Performing SMR before 12 years of age can lead to severe **facial growth disturbances**, such as a saddle nose deformity, due to interference with the septal growth plate. *Rhinoplasty* - While rhinoplasty is generally delayed until nasal growth is complete (around 15-16 years old for girls, 16-17 for boys), it is not absolutely contraindicated structurally before 12 in the same way SMR is. - The concern is primarily about final aesthetic outcome and patient maturity, not direct damage to major growth centers. *Septoplasty* - **Septoplasty** can be performed in younger children for severe nasal obstruction, especially if it significantly impacts breathing or sleep. - It involves reshaping or repositioning the **septal cartilage and bone** with minimal removal, preserving growth potential. *Antral puncture* - **Antral puncture** (or antral lavage) is a procedure to drain the maxillary sinus and can be performed at any age when indicated for sinusitis. - It does not interfere with facial growth as it targets the sinus cavity walls and does not involve the nasal septum.

Q: A patient presents with a gradually progressive, painless mass persisting for 10 years. The mass is firm to nodular and shows variable consistency within different areas of the swelling. What is the most probable diagnosis?

Pleomorphic adenoma. ***Pleomorphic adenoma*** - A **gradually progressive**, **painless mass** that has been present for 10 years, with a **firm to nodular** consistency and variability at different sites, is highly characteristic of a pleomorphic adenoma. - This benign tumor of salivary glands is known for its **slow growth** and **variable histological composition**, leading to its characteristic consistency. *Dermoid cyst* - Dermoid cysts are typically **present from birth** or early childhood and tend to be **soft and doughy** in consistency, rather than firm or nodular with variable consistency. - While painless, their growth pattern and texture differ from the described mass. *Malignancy* - A mass that has been present for **10 years** and is still described as **gradually progressive** but painless is less likely to be a malignancy, as most malignant tumors tend to grow more rapidly and often present with pain or other symptoms over such a long period. - Malignancies usually demonstrate a more infiltrative and aggressive growth pattern. *Sebaceous cyst* - A sebaceous cyst (epidermoid cyst) typically presents as a **smooth, movable, dome-shaped lump** and contains a cheesy, malodorous material, which is not consistent with a firm to nodular mass with varying consistency. - While they can be long-standing and painless, their characteristic feel and contents are different.

Q: A 43 year old woman came with a large abscess in the middle of the right posterior triangle of the neck. The physician incised and drained the abscess. Five days later the patient noticed that she could not raise her right arm above her head to brush her hair. What is the cause

Injury to the spinal accessory nerve. ***Injury to the spinal accessory nerve*** - The **spinal accessory nerve (CN XI)** innervates the **sternocleidomastoid** and **trapezius muscles**. - Damage to this nerve, particularly during surgery in the posterior triangle of the neck, can lead to weakness in **shrugging the shoulders** and difficulty **abducting the arm above 90 degrees** (due to trapezius dysfunction). *Injury to the suprascapular nerve* - The **suprascapular nerve** innervates the **supraspinatus** and **infraspinatus muscles**, which are involved in the initial 0-15 degrees of abduction and external rotation, respectively. - Damage would primarily affect these movements, not the ability to extend the hand above the head (which involves arm elevation beyond 90 degrees). *Damage to the scalenus medius muscle* - The **scalenus medius muscle** is primarily involved in **neck flexion and lateral flexion**, and elevating the second rib during forced inspiration. - Damage to this muscle would not directly impair the ability to raise the arm overhead. *Infection spread to the shoulder joint* - While infection could cause pain and inflammation, leading to reduced range of motion, it's less likely to result in a **specific neurological deficit** observed shortly after an incision and drainage. - An infection spreading to the shoulder joint would present with **symptoms of septic arthritis** (e.g., severe pain, swelling, fever), which are not mentioned.

Q: High tracheostomy is NOT done in:-

Laryngeal carcinoma. ***Laryngeal carcinoma*** - High tracheostomy is **contraindicated** in laryngeal carcinoma due to risk of **stomal recurrence** and tumor seeding at the tracheostomy site. - It can contaminate the **surgical field** and compromise oncological principles, making future surgical resection more complex. *Laryngomalacia* - High tracheostomy **is indicated** in severe laryngomalacia when there is significant **respiratory distress** or failure to thrive. - It bypasses the **collapsing supraglottic structures** and provides a secure airway above the level of obstruction. *Vocal cord palsy* - High tracheostomy **may be performed** in bilateral vocal cord palsy causing severe **airway obstruction** and stridor. - It provides immediate airway relief while preserving options for future **vocal cord procedures** or reinnervation surgeries. *Subglottic stenosis* - High tracheostomy **is appropriate** in subglottic stenosis as it places the stoma **above the level of stenosis**. - It allows for **staged surgical repair** of the stenotic segment while maintaining airway patency during reconstruction procedures.

Q: All of the following statements are true about Frey's Syndrome except

Sympathetic nerve involvement is the primary cause. ***Sympathetic nerve involvement is the primary cause*** - **This is FALSE (Correct answer for EXCEPT question)** - Frey's syndrome is **NOT** caused by sympathetic nerve involvement - The primary cause is **aberrant regeneration of severed PARASYMPATHETIC fibers** of the auriculotemporal nerve - These parasympathetic fibers mistakenly re-innervate sweat glands (which are sympathetically innervated) instead of the parotid gland - This misdirection causes gustatory sweating during meals *Less chances with enucleation than parotidectomy* - **TRUE** - Enucleation is a less extensive procedure compared to complete parotidectomy - Less tissue removal means less nerve disruption and lower risk of auriculotemporal nerve damage - The risk of Frey's syndrome is directly proportional to the extent of parotid tissue removal *Gustatory sweating* - **TRUE** - This is the hallmark symptom of Frey's syndrome - Characterized by sweating on the skin over the parotid region in response to salivary stimuli (smelling, seeing, or eating food) - Results from misdirected parasympathetic fibers stimulating sweat glands instead of salivary tissue *Aberrant misdirection of parasympathetic fibers of auriculotemporal nerve* - **TRUE** - This is the correct pathophysiological mechanism underlying Frey's syndrome - Following injury to the auriculotemporal nerve during parotid surgery, regenerating parasympathetic secretomotor fibers become misdirected - These fibers intended for the parotid gland instead innervate sweat glands in the overlying skin

Question 1

Treatment of choice for angiofibroma -

Accepted Answer

Surgery

Answer

Radiotherapy

Answer

Combination of treatments (Surgery and Radiotherapy)

Answer

Chemotherapy

Question 2

Which cancers can cause referred otalgia (referred pain in the ear)? Select the most comprehensive answer.

Accepted Answer

Cancer of the pharynx, oral cavity, and larynx

Answer

Cancer of the pharynx

Answer

Cancer of the oral cavity

Answer

Cancer of the larynx

Question 3

Le Forte II is fracture of?

Accepted Answer

Fracture involving zygomatic process of the maxilla, floor of orbit, root of nose

Answer

Fracture involving midline of the palate and zygomatico-maxillary suture

Answer

Fracture involving alveolar ridge

Answer

Fracture involving lateral side of hard palate

Question 4

True about carotid body tumor is all except:

Accepted Answer

First-bite syndrome is a known complication

Answer

Lyre sign on angiography

Answer

Hereditary predisposition

Answer

Benign

Question 5

A high tracheostomy may be indicated in:

Accepted Answer

Severe bilateral vocal cord paralysis

Answer

Advanced carcinoma of the larynx

Answer

Chronic scleroma involving the larynx

Answer

Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)

Question 6

Which of the following surgeries is contraindicated below 12 years of age?

Accepted Answer

SMR

Answer

Rhinoplasty

Answer

Septoplasty

Answer

Antral puncture

Question 7

A patient presents with a gradually progressive, painless mass persisting for 10 years. The mass is firm to nodular and shows variable consistency within different areas of the swelling. What is the most probable diagnosis?

Accepted Answer

Pleomorphic adenoma

Answer

Dermoid cyst

Answer

Malignancy

Answer

Sebaceous cyst

Question 8

A 43 year old woman came with a large abscess in the middle of the right posterior triangle of the neck. The physician incised and drained the abscess. Five days later the patient noticed that she could not raise her right arm above her head to brush her hair. What is the cause

Accepted Answer

Injury to the spinal accessory nerve

Answer

Injury to the suprascapular nerve

Answer

Damage to the scalenus medius muscle

Answer

Infection spread to the shoulder joint

Question 9

High tracheostomy is NOT done in:-

Accepted Answer

Laryngeal carcinoma

Answer

Vocal cord palsy

Answer

Subglottic stenosis

Answer

Laryngomalacia

Question 10

All of the following statements are true about Frey's Syndrome except

Accepted Answer

Sympathetic nerve involvement is the primary cause

Answer

Less chances with enucleation than parotidectomy

Answer

Gustatory sweating

Answer

Aberrant misdirection of parasympathetic fibers of auriculotemporal nerve

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?