Head and Neck Surgery Practice Questions

Q: During a neck dissection, a surgeon inadvertently cuts a nerve that results in a deviation of the tongue. Which nerve is likely severed?

Hypoglossal nerve; weakness in tongue movement. ***Hypoglossal nerve; weakness in tongue movement*** - Damage to the **hypoglossal nerve (CN XII)** results in paralysis of the **intrinsic and extrinsic muscles of the tongue** on the ipsilateral side. - Unopposed action of the contralateral tongue muscles causes the tongue to deviate **towards the side of the lesion** when protruded. *Vagus nerve; loss of soft palate elevation* - The **vagus nerve (CN X)** innervates most muscles of the **soft palate, pharynx, and larynx**. - Injury to the vagus nerve causes issues like hoarseness, dysphagia, and a **uvula deviation away from the lesioned side**, due to paralysis of the ipsilateral palatoglossal and palatopharyngeal muscles. *Accessory nerve; shoulder droop* - The **accessory nerve (CN XI)** primarily innervates the **sternocleidomastoid** and **trapezius muscles**. - Damage to this nerve would lead to **weakness in head rotation, shrugging the shoulders**, and elevating the arm above 90 degrees. *Glossopharyngeal nerve; loss of taste sensation* - The **glossopharyngeal nerve (CN IX)** provides sensory innervation to the posterior third of the tongue for taste and general sensation, and motor innervation to the **stylopharyngeus muscle**. - A lesion would primarily result in **loss of taste and sensation on the posterior tongue**, and potentially difficulty swallowing, but not tongue deviation.

Q: A 25-year-old male presents with a history of recurrent tonsillitis and obstructive sleep apnea. Physical examination reveals significantly enlarged tonsils. What is the recommended treatment?

Tonsillectomy. ***Tonsillectomy*** - This patient presents with both **recurrent tonsillitis** and **obstructive sleep apnea (OSA)** due to significantly enlarged tonsils, which are classic indications for a tonsillectomy. - Removing the enlarged tonsils directly addresses the source of both the recurrent infections and the airway obstruction. *Antibiotic therapy* - While antibiotics treat acute episodes of **bacterial tonsillitis**, they do not prevent recurrence or address the underlying anatomical obstruction causing **OSA**. - Long-term use of antibiotics for recurrent infections is not a sustainable or definitive solution and carries risks of **antibiotic resistance**. *Watchful waiting* - This approach is generally reserved for mild, infrequent tonsillitis without significant complications like **OSA**. - In this case, the presence of **obstructive sleep apnea** indicates a more severe condition requiring intervention to prevent long-term health consequences. *Steroid injections* - **Steroid injections** could temporarily reduce tonsil inflammation but would not provide a lasting solution for recurrent tonsillitis or chronic anatomical obstruction causing **OSA**. - They are not a standard treatment for either recurrent tonsillitis or **obstructive sleep apnea** in the long term.

Q: A 55-year-old male presents with a painless neck mass and a history of chronic tobacco use. Fine needle aspiration cytology reveals squamous cell carcinoma. What is the most likely primary site of the carcinoma?

Larynx. ***Larynx*** - **Squamous cell carcinoma** (SCC) of the larynx frequently presents as a painless neck mass due to nodal metastasis, and **chronic tobacco use** is a major risk factor. - The larynx is a common primary site for SCC in individuals with a significant smoking history, often detected as a neck mass representing a **metastatic lymph node**. *Thyroid gland* - Thyroid masses are typically identified as discrete thyroid nodules, and while they can be SCC, it's far less common as a primary than other head and neck sites with a history of tobacco use. - **Papillary** and **follicular carcinomas** are more common thyroid malignancies, and smoking is not a primary risk factor for these. *Salivary gland* - Salivary gland tumors are often primary **adenocarcinomas** or **mucoepidermoid carcinomas**, not typically SCC in the absence of pre-existing squamous metaplasia. - While salivary gland masses can occur in the neck region, SCC as a primary here is relatively rare compared to other head and neck sites linked to tobacco. *Nasopharynx* - **Nasopharyngeal carcinoma** is typically associated with **Epstein-Barr virus (EBV) infection** and has a higher prevalence in certain endemic regions (e.g., Southeast Asia), not primarily linked to tobacco use in the same way as laryngeal SCC. - Nasopharyngeal masses can cause symptoms like **nasal obstruction**, **epistaxis**, and **hearing loss** due to eustachian tube dysfunction, which are not mentioned here.

Q: A patient presents with a rapidly growing neck mass and difficulty breathing. What is the initial management for this patient?

Immediate airway management. Immediate airway management [1], [2] - A rapidly growing neck mass causing difficulty breathing indicates potential airway obstruction, which is a life-threatening emergency. [1], [2] - Securing the airway with measures like intubation or tracheostomy takes precedence over diagnostic procedures. [1], [2] Biopsy - While a biopsy is crucial for diagnosing the nature of a neck mass, it is a diagnostic procedure that can be delayed until the patient's airway is stable. - Performing a biopsy on an unstable patient with airway compromise can worsen their condition due to potential bleeding or swelling. CT scan - A CT scan is a valuable imaging modality for characterizing a neck mass and assessing its extent, but like biopsy, it is a diagnostic tool. - Delaying airway management for a CT scan in a patient with respiratory distress can lead to respiratory arrest. Observation - Observation is inappropriate when a patient presents with a rapidly growing neck mass causing difficulty breathing, as the situation is acute and requires immediate intervention. - Waiting for the condition to resolve spontaneously or worsen can have fatal consequences.

Q: A 50-year-old male presents with progressive hoarseness and difficulty swallowing following thyroid surgery. Laryngoscopy reveals bilateral vocal cord paralysis. What is the most likely cause?

Thyroid surgery. ***Thyroid surgery*** - **Bilateral vocal cord paralysis** is a severe complication of **thyroid surgery**, typically due to injury to the **recurrent laryngeal nerves**. - This nerve damage can lead to both **hoarseness** (aphonia or dysphonia) and **difficulty swallowing** (dysphagia) due to impaired vocal cord movement. *Laryngeal carcinoma* - While it can cause hoarseness and dysphagia, a carcinoma typically presents as a **mass lesion** on laryngoscopy and often causes **unilateral paralysis** initially. - **Bilateral vocal cord paralysis** due to carcinoma is less common without significant tumor burden visible, and the question does not mention any mass. *Vocal cord nodules* - **Vocal cord nodules** primarily cause hoarseness and are typically visible as **small, paired lesions** on the vocal cords, often associated with voice misuse. - They do not cause **vocal cord paralysis** or significant difficulty swallowing, as vocal cord movement is preserved. *Laryngitis* - **Laryngitis** causes hoarseness or loss of voice due to **inflammation** and swelling of the vocal cords. - It does not cause **vocal cord paralysis** or difficulty swallowing, and laryngoscopy would show diffuse inflammation rather than immobility.

Q: During a tonsillectomy, which structure is at risk of injury that could potentially lead to hemorrhage?

Tonsillar branch of facial artery. ***Tonsillar branch of facial artery*** - The **tonsillar branch of the facial artery** (also called the tonsillar artery) is the **primary arterial supply** to the palatine tonsil. - It pierces the **superior constrictor muscle** to enter the tonsillar fossa and is located within the **lateral aspect of the tonsillar bed**. - This vessel is the **most common source of hemorrhage** during and after tonsillectomy, causing both **primary** (within 24 hours) and **secondary** (after 24 hours) post-tonsillectomy bleeding. - Surgeons routinely encounter and must control this vessel during dissection of the tonsil from its fossa, making it the **most clinically relevant vessel at risk**. *Internal carotid artery* - The **internal carotid artery** lies posterolateral to the tonsillar fossa, separated by the **superior constrictor muscle** and pharyngeal fascia. - Injury to this vessel during tonsillectomy is **extremely rare** and would require deep, aberrant dissection through the pharyngeal wall or presence of an anatomical anomaly. - While such an injury would be catastrophic, it is **not a routine surgical risk** in standard tonsillectomy technique. *Lingual artery* - The **lingual artery** primarily supplies the tongue and courses deep in the floor of the mouth. - It is anatomically **distant from the tonsillar fossa** and not at risk during standard tonsillectomy. *Recurrent laryngeal nerve* - The **recurrent laryngeal nerve** is located in the **tracheoesophageal groove** in the lower neck, far removed from the tonsillar fossa. - This is a **nerve** (not a vessel), and injury would cause **hoarseness**, not hemorrhage. - It is not at risk during tonsillectomy.

Q: During a tonsillectomy, which major artery must be carefully avoided because of its close proximity to the tonsils?

Facial artery. ***Facial artery*** - The **tonsillar branch of the facial artery** is the primary arterial supply to the palatine tonsil and lies in **direct proximity to the tonsillar bed**. - This branch ascends along the lateral surface of the superior pharyngeal constrictor muscle and penetrates it to reach the tonsil, making it the most commonly encountered artery during tonsillectomy. - It is the **major artery that must be carefully identified and controlled** during dissection to prevent significant intraoperative and postoperative hemorrhage. - The facial artery itself arises from the external carotid artery and is a substantial vessel whose injury can cause considerable bleeding. *External carotid artery* - While the **external carotid artery** is the parent vessel that gives rise to branches supplying the tonsils, it is located in the carotid sheath **lateral to the pharynx and NOT in close proximity** to the tonsillar bed during routine tonsillectomy. - Surgeons do not typically encounter this artery in the standard surgical field unless there is aberrant anatomy or extensive deep dissection beyond normal planes. *Maxillary artery* - The **maxillary artery** is a terminal branch of the external carotid artery located in the **infratemporal fossa**, which is not in direct proximity to the tonsillar fossa. - This artery supplies deeper structures and is not routinely at risk during standard tonsillectomy procedures. *Internal carotid artery* - The **internal carotid artery** lies posterolateral to the tonsil, typically **1-2.5 cm away** and separated by the superior pharyngeal constrictor muscle and other fascial layers. - While injury to this artery is a rare but **catastrophic complication**, it is not considered in close proximity to the routine surgical dissection plane and is not the primary vascular structure of concern during standard tonsillectomy.

Q: A 45-year-old male presents with a painless, enlarging neck mass that has been gradually increasing in size over several months. He has a history of smoking and alcohol use. What is the most likely diagnosis?

Metastatic squamous cell carcinoma of the head and neck. ***Squamous cell carcinoma of the head and neck*** - The **painless, enlarging neck mass** in a 45-year-old male with a history of **smoking and alcohol use** is highly indicative of squamous cell carcinoma [1]. - This type of cancer commonly arises in the **head and neck region**, particularly in individuals with these risk factors [1][3]. *Branchial cleft cyst* - Typically presents as a **painless, mobile mass** but usually occurs in younger individuals, not a 45-year-old male with risk factors like smoking. - Branchial cleft cysts are often **localized** and do not show the **gradual increase** in size characteristic of malignancies. *Thyroid nodule* - While thyroid nodules can present as neck masses, they are often **not painless** and usually have different risk factors that do not prominently include smoking and alcohol use. - The **patient's age** and background more strongly suggest a malignant process over a benign thyroid condition. *Benign salivary gland tumor* - Generally presents as a **painful or asymptomatic mass** but is less likely to be painless and increasing in size without associated symptoms [2]. - The **association with smoking** and the nature of the mass make malignant tumors like squamous cell carcinoma a more plausible diagnosis in this scenario.

Q: A 45-year-old man presents with a painless neck mass and hoarseness. On examination, there is a firm, fixed mass in the left anterior triangle of the neck. Which investigation is most appropriate to establish the diagnosis?

Fine-needle aspiration biopsy. ***Fine-needle aspiration biopsy*** - A **fine-needle aspiration biopsy (FNAB)** is the most appropriate investigation to **establish the cytological diagnosis** of a solid neck mass. It helps differentiate between benign and malignant conditions. - It is a **minimally invasive procedure** that can be performed in the office, offering a quick and relatively inexpensive way to obtain tissue for examination. - **Clinical note:** In a patient with hoarseness and a neck mass, **laryngoscopy should also be performed** to evaluate for a primary laryngeal/hypopharyngeal lesion, as hoarseness suggests vocal cord involvement. *CT scan of the neck* - A CT scan is excellent for evaluating the **extent of a lesion**, its relationship to surrounding structures, and for **staging confirmed malignancies**. - However, it does not provide a **definitive histological or cytological diagnosis** and should follow tissue diagnosis or be used in conjunction with it. - CT is valuable for assessing the **deep extent of invasion** and involvement of vascular structures. *MRI of the neck* - MRI offers superior **soft tissue contrast** compared to CT and is particularly useful for assessing **nerve involvement, perineural spread**, or evaluating the extent of soft tissue invasion. - Like CT, it provides detailed imaging but does not establish a **tissue diagnosis**, which is crucial for determining the nature of the mass. *Ultrasound of the neck* - Ultrasound is useful for determining if a neck mass is **solid or cystic** and for **guiding fine-needle aspiration biopsy**. - It can characterize the mass and assess cervical lymph nodes, but cannot provide a **definitive cytological diagnosis** without a biopsy. - It is operator-dependent and less useful for deep-seated masses.

Q: A patient with a stab wound to the neck presents with difficulty breathing and hoarseness. Which structure is most likely to be injured?

Recurrent laryngeal nerve. ***Recurrent laryngeal nerve*** - Injury causes **hoarseness** due to vocal cord paralysis - Can cause **difficulty breathing** especially if bilateral injury occurs - Anatomical course in the neck makes it vulnerable to penetrating trauma - Classic presentation matches this patient's symptoms perfectly *Thyroid gland* - Injury typically causes bleeding or hematoma formation - Does not directly cause hoarseness or breathing difficulty - Symptoms could occur only if large hematoma compresses adjacent structures (recurrent laryngeal nerve or trachea) *Internal carotid artery* - Injury presents with severe bleeding and expanding hematoma - May cause neurological deficits (stroke, ischemia) - Does not directly explain hoarseness or respiratory symptoms *Jugular vein* - Injury results in significant venous bleeding - Risk of air embolism in neck vein injuries - Would not cause hoarseness or acute breathing difficulty unless massive hematoma compresses airway

Question 1

During a neck dissection, a surgeon inadvertently cuts a nerve that results in a deviation of the tongue. Which nerve is likely severed?

Accepted Answer

Hypoglossal nerve; weakness in tongue movement

Answer

Vagus nerve; loss of soft palate elevation

Answer

Accessory nerve; shoulder droop

Answer

Glossopharyngeal nerve; loss of taste sensation

Question 2

A 25-year-old male presents with a history of recurrent tonsillitis and obstructive sleep apnea. Physical examination reveals significantly enlarged tonsils. What is the recommended treatment?

Accepted Answer

Tonsillectomy

Answer

Antibiotic therapy

Answer

Watchful waiting

Answer

Steroid injections

Question 3

A 55-year-old male presents with a painless neck mass and a history of chronic tobacco use. Fine needle aspiration cytology reveals squamous cell carcinoma. What is the most likely primary site of the carcinoma?

Accepted Answer

Larynx

Answer

Thyroid gland

Answer

Salivary gland

Answer

Nasopharynx

Question 4

A patient presents with a rapidly growing neck mass and difficulty breathing. What is the initial management for this patient?

Accepted Answer

Immediate airway management

Answer

Biopsy

Answer

CT scan

Answer

Observation

Question 5

A 50-year-old male presents with progressive hoarseness and difficulty swallowing following thyroid surgery. Laryngoscopy reveals bilateral vocal cord paralysis. What is the most likely cause?

Accepted Answer

Thyroid surgery

Answer

Laryngeal carcinoma

Answer

Vocal cord nodules

Answer

Laryngitis

Question 6

During a tonsillectomy, which structure is at risk of injury that could potentially lead to hemorrhage?

Accepted Answer

Tonsillar branch of facial artery

Answer

Recurrent laryngeal nerve

Answer

Internal carotid artery

Answer

Lingual artery

Question 7

During a tonsillectomy, which major artery must be carefully avoided because of its close proximity to the tonsils?

Accepted Answer

Facial artery

Answer

Maxillary artery

Answer

Internal carotid artery

Answer

External carotid artery

Question 8

A 45-year-old male presents with a painless, enlarging neck mass that has been gradually increasing in size over several months. He has a history of smoking and alcohol use. What is the most likely diagnosis?

Accepted Answer

Metastatic squamous cell carcinoma of the head and neck

Answer

Branchial cleft cyst

Answer

Thyroid nodule

Answer

Benign salivary gland tumor

Question 9

A 45-year-old man presents with a painless neck mass and hoarseness. On examination, there is a firm, fixed mass in the left anterior triangle of the neck. Which investigation is most appropriate to establish the diagnosis?

Accepted Answer

Fine-needle aspiration biopsy

Answer

CT scan of the neck

Answer

MRI of the neck

Answer

Ultrasound of the neck

Question 10

A patient with a stab wound to the neck presents with difficulty breathing and hoarseness. Which structure is most likely to be injured?

Accepted Answer

Recurrent laryngeal nerve

Answer

Thyroid gland

Answer

Internal carotid artery

Answer

Jugular vein

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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