Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 411: Treatment of choice for angiofibroma -

A. Radiotherapy
B. Combination of treatments (Surgery and Radiotherapy)
C. Chemotherapy
D. Surgery (Correct Answer)

Explanation: ***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.

Question 412: Which cancers can cause referred otalgia (referred pain in the ear)? Select the most comprehensive answer.

A. Cancer of the pharynx
B. Cancer of the oral cavity
C. Cancer of the pharynx, oral cavity, and larynx (Correct Answer)
D. Cancer of the larynx

Explanation: ***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.

Question 413: Le Forte II is fracture of?

A. Fracture involving midline of the palate and zygomatico-maxillary suture
B. Fracture involving alveolar ridge
C. Fracture involving lateral side of hard palate
D. Fracture involving zygomatic process of the maxilla, floor of orbit, root of nose (Correct Answer)

Explanation: ***Fracture involving zygomatic process of the maxilla, floor of orbit, root of nose*** - A **Le Fort II fracture**, also known as a **pyramidal fracture**, involves the **nasal bones**, **frontal processes of the maxilla**, **lacrimal bones**, and the **zygomaticomaxillary suture**. - This fracture pattern creates a pyramid-shaped detached segment of the midface, including the **floor of the orbit** and the **zygomatic process of the maxilla**. *Fracture involving midline of the palate and zygomatico-maxillary suture* - This description is characteristic of a **Le Fort I fracture**, which involves the **maxilla separating from the pterygoid plates** and nasal septum, producing a floating palate. - A **Le Fort I fracture** typically involves the **midline of the palate** and may extend to the zygomaticomaxillary suture but often inferiorly. *Fracture involving alveolar ridge* - This describes a **dentoalveolar fracture**, which is a localized fracture of the **alveolar process** containing teeth, without involving the major midfacial structures. - These fractures are typically confined to the tooth-bearing part of the maxilla or mandible and are not classified as a Le Fort fracture. *Fracture involving lateral side of hard palate* - While a fracture extending to the lateral side of the hard palate can occur with various midfacial traumas, this specific description is not the defining characteristic of any of the Le Fort fracture classifications. - Le Fort fractures involve comprehensive patterns of maxillary and midfacial separation, rather than isolated fractures of the lateral hard palate.

Question 414: True about carotid body tumor is all except:

A. Lyre sign on angiography
B. Hereditary predisposition
C. Benign
D. First-bite syndrome is a known complication (Correct Answer)

Explanation: ***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

Question 415: A high tracheostomy may be indicated in:

A. Advanced carcinoma of the larynx
B. Severe bilateral vocal cord paralysis (Correct Answer)
C. Chronic scleroma involving the larynx
D. Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)

Explanation: ***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.

Question 416: Which of the following surgeries is contraindicated below 12 years of age?

A. SMR (Correct Answer)
B. Rhinoplasty
C. Septoplasty
D. Antral puncture

Explanation: ***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.

Question 417: 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?

A. Dermoid cyst
B. Malignancy
C. Sebaceous cyst
D. Pleomorphic adenoma (Correct Answer)

Explanation: ***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.

Question 418: 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

A. Injury to the suprascapular nerve
B. Injury to the spinal accessory nerve (Correct Answer)
C. Damage to the scalenus medius muscle
D. Infection spread to the shoulder joint

Explanation: ***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.

Question 419: High tracheostomy is done in:-

A. Vocal cord palsy
B. Laryngeal carcinoma (Correct Answer)
C. Subglottic stenosis
D. Laryngomalacia

Explanation: ***Laryngeal carcinoma*** - A high tracheostomy, often performed above the second tracheal ring, is indicated in **laryngeal carcinoma** to bypass the obstruction caused by the tumor and ensure a clear airway. - This position provides a more superior opening, which can be crucial when the lower trachea is needed for potential surgical resection or reconstruction, particularly in cases involving extensive laryngeal involvement. *Vocal cord palsy* - **Vocal cord palsy** primarily affects phonation and can cause aspiration, but it typically does not cause acute or severe enough airway obstruction to warrant an emergency tracheostomy. - Airway management for vocal cord palsy often involves voice therapy, glottic augmentation, or arytenoid adduction, rather than high tracheostomy. *Subglottic stenosis* - **Subglottic stenosis** involves narrowing below the vocal cords and usually requires a tracheostomy that is placed **below the level of the stenosis** to bypass the obstruction, often necessitating a low or standard tracheostomy. - A high tracheostomy might be within or too close to the stenotic segment, making it ineffective or surgically challenging. *Laryngomalacia* - **Laryngomalacia** is a congenital condition where the larynx collapses inward during inspiration, causing stridor, most commonly resolving spontaneously by 18-24 months. - Tracheostomy is reserved for severe cases with significant respiratory distress or failure to thrive, and the placement is usually standard or low to ensure bypass of the floppy laryngeal tissues, not typically a high tracheostomy.

Question 420: All of the following statements are true about Frey's Syndrome except

A. Less chances with enucleation than parotidectomy
B. Gustatory sweating
C. Aberrant misdirection of parasympathetic fibers of auriculotemporal nerve
D. Sympathetic nerve involvement is the primary cause (Correct Answer)

Explanation: ***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

Practice by Chapter

Salivary Gland Diseases

Practice Questions

Thyroid Gland Disorders

Practice Questions

Parathyroid Gland Disorders

Practice Questions

Neck Masses Evaluation

Practice Questions

Oral Cavity Lesions

Practice Questions

Laryngeal Disorders

Practice Questions

Head and Neck Cancer

Practice Questions

Reconstructive Techniques in Head and Neck Surgery

Practice Questions

Surgical Management of Sleep Apnea

Practice Questions

Airway Management in Head and Neck Surgery

Practice Questions

Surgical Approaches to the Neck

Practice Questions

Neck Dissection Techniques

Practice Questions

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