Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 41: Which is the ideal position for nasogastric tube insertion?

A. Sitting with neck extended
B. Supine with neck flexed
C. Supine with neck extended
D. Sitting with neck flexed (Correct Answer)

Explanation: **Explanation:** The ideal position for nasogastric (NG) tube insertion is **Sitting with the neck flexed** (often referred to as the "High Fowler’s position with a chin-tuck maneuver"). **Why it is correct:** The primary goal during NG tube insertion is to ensure the tube enters the esophagus rather than the trachea. Flexing the neck (chin-to-chest) performs two critical anatomical functions: 1. It physically narrows the airway opening by bringing the larynx forward. 2. It opens the posterior oropharyngeal path toward the esophagus. When the patient is sitting upright, gravity assists the passage of the tube, and the flexion maneuver makes the esophagus the path of least resistance. **Why the other options are incorrect:** * **Neck Extended (Options A & C):** Extending the neck straightens the air passage toward the trachea. This significantly increases the risk of accidental tracheal intubation and aspiration. * **Supine Position (Options B & C):** While NG tubes can be inserted in supine patients (e.g., in the ICU), it is not "ideal." The supine position increases the risk of gagging and pulmonary aspiration of gastric contents compared to the sitting position. **Clinical Pearls for NEET-PG:** * **Measurement:** The length of the tube to be inserted is determined by the distance from the **Nose to the Earlobe to the Xiphoid process (NEX measurement)**. * **Gold Standard for Confirmation:** While auscultation of an air bolus ("whoosh test") is common, the **Chest X-ray** is the most reliable method to confirm correct placement before starting feeds. * **pH Testing:** A gastric aspirate with a **pH < 5.5** is a reliable bedside indicator of gastric placement. * **Coiling:** If the patient starts coughing or gasping, the tube is likely in the larynx; withdraw immediately.

Question 42: What is true about carotid body tumors?

A. Arises from the pharyngeal wall
B. Arises from baroreceptor cells
C. Commonly seen in individuals residing at high altitudes (Correct Answer)
D. All of the above

Explanation: **Explanation:** **1. Why Option C is Correct:** Carotid body tumors (CBTs) are **paragangliomas** arising from the chemoreceptor cells located at the carotid bifurcation. Chronic hypoxia is a major stimulus for hyperplasia of these cells. Individuals living at **high altitudes** experience chronic hypoxemia, which triggers compensatory hypertrophy and hyperplasia of the carotid body, significantly increasing the incidence of these tumors compared to populations at sea level. **2. Why Other Options are Incorrect:** * **Option A:** CBTs do not arise from the pharyngeal wall. They are located in the **adventitia of the carotid bifurcation** within the carotid sheath. While a large tumor may bulge into the oropharynx, its anatomical origin is vascular/neural. * **Option B:** This is a common distractor. The carotid body consists of **chemoreceptors** (sensing $O_2$, $CO_2$, and pH), not baroreceptors. Baroreceptors (sensing pressure) are located in the **carotid sinus**, which is a dilation of the internal carotid artery. **3. Clinical Pearls for NEET-PG:** * **Fontaine’s Sign:** The tumor is mobile horizontally but fixed vertically (due to its attachment within the carotid bifurcation). * **Lyre Sign:** On angiography, the tumor classically causes widening/splaying of the bifurcation of the internal and external carotid arteries. * **Shamblin Classification:** Used to grade the tumor based on its involvement/encasement of the carotid vessels. * **Histology:** Characterized by **Zellballen patterns** (nests of chief cells surrounded by sustentacular cells). * **Rule of 10s:** Approximately 10% are bilateral, 10% are familial, and 10% are malignant.

Question 43: In which one of the following, perineural invasion in head and neck cancer is most commonly seen?

A. Adenocarcinoma
B. Adenoid cystic carcinoma (Correct Answer)
C. Basal cell adenoma
D. Squamous cell carcinoma

Explanation: **Explanation:** **Adenoid cystic carcinoma (ACC)** is the correct answer because it is classically characterized by its high propensity for **perineural invasion (PNI)**. This tumor typically arises in the minor salivary glands (most commonly the palate) and the submandibular gland. The tumor cells have a unique affinity for nerve sheaths, often spreading far beyond the visible tumor margins via cranial nerves (e.g., the facial nerve or trigeminal nerve). This characteristic explains the high rates of local recurrence and the frequent clinical presentation of pain or nerve palsies. **Analysis of Incorrect Options:** * **Adenocarcinoma:** While it can show PNI, it is not its defining or most common feature compared to ACC. * **Basal cell adenoma:** This is a **benign** salivary gland tumor. Perineural invasion is a hallmark of malignancy; therefore, it is not seen in benign lesions. * **Squamous cell carcinoma (SCC):** SCC is the most common head and neck cancer overall and *can* exhibit PNI (especially in high-grade cases), but it is not as pathognomonic or frequent as it is in Adenoid Cystic Carcinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Histology of ACC:** Look for the characteristic **"Swiss cheese" appearance** (Cribriform pattern). * **Spread:** ACC is known for "skip lesions" along nerves and has a high rate of **distant metastasis** (most commonly to the **lungs**) via the bloodstream, even when local lymph nodes are negative. * **Prognosis:** It is a slow-growing but relentless "indolent" tumor with a poor long-term prognosis. * **Treatment:** Radical surgical excision with wide margins followed by adjuvant radiotherapy is the standard of care due to the risk of microscopic perineural spread.

Question 44: What anatomical structures are preserved during a radical neck dissection?

A. Carotid arteries (Correct Answer)
B. Jugular vein
C. Accessory nerve
D. Sternocleidomastoid muscle

Explanation: ### Explanation In surgical oncology, understanding the classification of neck dissections is vital for NEET-PG. The distinction lies in which non-lymphatic structures are removed versus preserved. **1. Why Carotid Arteries are the Correct Answer:** A **Radical Neck Dissection (RND)**, as originally described by Crile, involves the removal of all lymph node groups from levels I to V. However, it specifically **preserves the carotid arteries** (Internal, External, and Common), the Vagus nerve, and the Hypoglossal nerve. These structures are essential for life and basic neurological function and are never routinely sacrificed unless there is direct, gross tumor invasion. **2. Why the Other Options are Incorrect:** The "Classical" Radical Neck Dissection is defined by the intentional removal of three specific non-lymphatic structures to ensure oncological clearance: * **Jugular vein (Internal Jugular Vein - IJV):** Removed in RND. * **Accessory nerve (Spinal Accessory Nerve - SAN):** Removed in RND, leading to shoulder drop/trapezius atrophy. * **Sternocleidomastoid muscle (SCM):** Removed in RND to access deep cervical nodes. **3. Clinical Pearls for NEET-PG:** * **Modified Radical Neck Dissection (MRND):** This is the most common variant where lymph nodes (I-V) are removed, but one or more of the three structures (SAN, IJV, SCM) are **preserved**. * *Type I:* SAN preserved. * *Type II:* SAN and IJV preserved. * *Type III (Functional Neck Dissection):* All three (SAN, IJV, SCM) are preserved. * **Selective Neck Dissection:** Only specific lymph node levels are removed (e.g., Supraomohyoid dissection for oral cavity cancers). * **High-Yield Fact:** The most common nerve injured during neck surgery causing "winged scapula" is the **Long Thoracic Nerve**, but the nerve routinely sacrificed in RND causing shoulder disability is the **Spinal Accessory Nerve**.

Question 45: What percentage of severe trauma is associated with extradural haematoma?

A. 35%
B. 10% (Correct Answer)
C. 25%
D. 50%

Explanation: **Explanation:** **1. Why the Correct Answer is Right:** Extradural Haematoma (EDH) is a neurosurgical emergency characterized by bleeding between the inner table of the skull and the dura mater. According to standard surgical textbooks (like Bailey & Love), EDH is found in approximately **10% of patients with severe head injuries**. It is most commonly associated with a skull fracture (80% of cases) that lacerates the **middle meningeal artery**, leading to a rapid accumulation of arterial blood. **2. Why the Other Options are Incorrect:** * **A (35%) and C (25%):** These percentages are too high for EDH. However, Subdural Haematoma (SDH) is significantly more common in severe trauma, occurring in roughly 25-30% of cases. * **D (50%):** This is an overestimation. While head trauma is common in poly-trauma, a specific focal lesion like EDH does not reach this frequency. **3. Clinical Pearls & High-Yield Facts for NEET-PG:** * **The "Lucid Interval":** A classic clinical feature where the patient regains consciousness after the initial impact before deteriorating again. While pathognomonic, it occurs in only about 1/3 of cases. * **Source of Bleed:** The most common source is the **anterior division of the middle meningeal artery**. * **Radiology:** On a non-contrast CT (NCCT) head, EDH appears as a **biconvex (lentiform), hyperdense** lesion that does not cross skull sutures (but can cross the midline). * **Management:** The treatment of choice for a symptomatic or large EDH is urgent **burr hole evacuation or craniotomy**. * **Prognosis:** If treated promptly, EDH has a better prognosis than SDH because the underlying brain parenchyma is often less damaged.

Question 46: What is true about thyroglossal duct cyst?

A. It is a remnant of the thyroglossal duct, often presenting as a midline neck mass.
B. The definitive surgical treatment is the Sistrunk procedure.
C. Surgical management involves excising the cyst, the thyroglossal tract, and a portion of the hyoid bone.
D. All of the above are true. (Correct Answer)

Explanation: A **thyroglossal duct cyst (TGDC)** is the most common congenital neck swelling, resulting from the failure of the thyroglossal duct to obliterate during the descent of the thyroid gland from the foramen cecum to its final pre-tracheal position. ### **Explanation of Options:** * **Option A:** TGDCs typically present as a **painless, mobile, midline neck mass** (usually at or below the level of the hyoid bone). A classic clinical sign is that the mass **moves upward on protrusion of the tongue** due to its attachment to the hyoid bone via the ductal remnant. * **Option B & C:** The **Sistrunk procedure** is the gold-standard surgical treatment. Because the ductal tract is intimately associated with the hyoid bone, simple excision leads to high recurrence rates (up to 50%). The Sistrunk procedure involves a "radical" excision of the **cyst**, the entire **thyroglossal tract**, and the **central portion of the hyoid bone** to ensure all epithelial remnants are removed. ### **High-Yield Clinical Pearls for NEET-PG:** * **Embryology:** The thyroid descends from the **foramen cecum** (junction of the anterior 2/3 and posterior 1/3 of the tongue). * **Most Common Site:** Subhyoid (65%). * **Diagnostic Must:** Always perform an **Ultrasound** or palpate for the thyroid gland pre-operatively to ensure the cyst is not the patient's only functioning (ectopic) thyroid tissue. * **Complication:** While usually benign, **Papillary Thyroid Carcinoma** is the most common malignancy found within a TGDC (1%). * **Recurrence:** The recurrence rate drops to <5% after a properly performed Sistrunk procedure.

Question 47: What is the treatment of choice for Warthin tumor?

A. Radical parotidectomy
B. Superficial parotidectomy (Correct Answer)
C. Superficial parotidectomy with neck dissection
D. Enucleation

Explanation: **Explanation:** Warthin tumor (also known as **Papillary Cystadenoma Lymphomatosum**) is the second most common benign salivary gland tumor, typically occurring in the tail of the parotid gland. **1. Why Superficial Parotidectomy is the Correct Answer:** The standard treatment for Warthin tumor is **Superficial Parotidectomy**. This involves removing the superficial lobe of the parotid gland while carefully preserving the facial nerve. This approach is preferred because it ensures complete removal of the tumor with a margin of healthy tissue, minimizing the risk of recurrence (which is about 2-5%) and avoiding the high risk of seeding associated with simpler procedures. **2. Why Other Options are Incorrect:** * **Radical Parotidectomy:** This involves sacrificing the facial nerve and is reserved for high-grade malignancies with nerve involvement. Warthin tumor is benign and does not require such aggressive surgery. * **Superficial Parotidectomy with Neck Dissection:** Neck dissection is indicated for malignant tumors with suspected nodal metastasis. Warthin tumor is benign and does not metastasize. * **Enucleation:** Simply "shelling out" the tumor carries a high risk of rupture and recurrence. While some modern literature discusses "extracapsular dissection," traditional enucleation is generally discouraged in standard surgical teaching for parotid tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Epidemiology:** Strongly associated with **smoking** and more common in **males** (though the gender gap is narrowing). * **Location:** Most common tumor to be **bilateral** (10%) or multicentric. * **Diagnosis:** On Technetium-99m pertechnetate scan, it appears as a **"Hot Nodule"** (due to the presence of oncocytes). * **Pathology:** Characterized by a double layer of epithelial cells (oncocytes) and a dense lymphoid stroma with germinal centers.

Question 48: Ludwig's Angina spreads by which route?

A. Lymphatics
B. Vascular route
C. Contiguity via fascial planes (Correct Answer)
D. Both Lymphatics and blood vessels

Explanation: **Explanation:** **Ludwig’s Angina** is a rapidly spreading, life-threatening cellulitis of the submandibular, sublingual, and submental spaces. **Why Option C is correct:** The hallmark of Ludwig’s Angina is that it is a **fascial space infection**, not a glandular one. It spreads by **contiguity via fascial planes** rather than through the lymphatic system. The infection typically originates from the second or third mandibular molars (80% of cases). The roots of these teeth lie below the **mylohyoid line**; thus, infection penetrates the lingual cortical bone and spreads directly into the submandibular space. From there, it travels via the fascial layers to involve the sublingual and submental spaces bilaterally. **Why other options are incorrect:** * **Options A & D:** Unlike cervical lymphadenitis, Ludwig’s Angina characteristically **spares the regional lymph nodes**. The absence of significant lymphadenopathy is a classic diagnostic feature. * **Option B:** While systemic sepsis can occur in advanced stages, the primary mode of initial spread is local anatomical extension through connective tissue planes, not the bloodstream. **Clinical Pearls for NEET-PG:** * **Most common cause:** Odontogenic infection (2nd/3rd mandibular molars). * **Clinical Presentation:** "Woody" or "Brawny" edema of the neck, elevation and protrusion of the tongue (causing airway obstruction), and "Hot potato voice." * **Microbiology:** Usually polymicrobial (Streptococci, Staphylococci, and anaerobes). * **Management:** The priority is **Airway Management** (often requiring tracheostomy if intubation fails). Treatment includes IV antibiotics and surgical incision and drainage if there is fluctuance or failed medical management.

Question 49: Surgery of choice for pleomorphic adenoma is:

A. Total parotidectomy
B. Superficial parotidectomy (Correct Answer)
C. Total parotidectomy with lymph node dissection
D. Radical parotidectomy

Explanation: ### Explanation **Pleomorphic Adenoma** (Benign Mixed Tumor) is the most common salivary gland tumor, most frequently involving the **superficial lobe of the parotid gland**. #### Why Superficial Parotidectomy is the Correct Choice: The standard surgical management for a pleomorphic adenoma located in the superficial lobe is **Superficial Parotidectomy** (also known as Suprafacial Parotidectomy). * **The Concept:** The tumor is typically surrounded by a "false capsule." Simple enucleation (shelling out the tumor) is strictly contraindicated because it leads to high recurrence rates due to microscopic pseudopods extending through the capsule. * **The Procedure:** Superficial parotidectomy involves removing the entire superficial lobe while identifying and **preserving the facial nerve**. This ensures a wide margin of healthy tissue, minimizing recurrence. #### Why Other Options are Incorrect: * **A. Total Parotidectomy:** This involves removing both the superficial and deep lobes. It is reserved for tumors involving the deep lobe or recurrent cases. It is not the primary choice for standard superficial tumors. * **C. Total Parotidectomy with Lymph Node Dissection:** Pleomorphic adenoma is a benign tumor and does not metastasize to lymph nodes. This aggressive approach is reserved for high-grade malignancies (e.g., Mucoepidermoid carcinoma). * **D. Radical Parotidectomy:** This involves the sacrifice of the facial nerve. It is only indicated in cases of frank malignancy where the nerve is directly involved or encased by the tumor. #### NEET-PG High-Yield Pearls: * **Most common site:** Tail of the parotid gland. * **Most common nerve injured:** Greater auricular nerve (leads to numbness over the ear lobe). * **Frey’s Syndrome:** A late complication of parotidectomy (diagnosed by the Minor’s Starch-Iodine test). * **Malignant transformation:** Occurs in ~3-5% of cases, known as *Carcinoma ex-pleomorphic adenoma*.

Question 50: Which of the following statements regarding lip carcinoma is false?

A. Smoking is a significant risk factor.
B. It is more common in the lower lip.
C. Lower lip carcinoma has a worse prognosis compared to other oral cancers. (Correct Answer)
D. Distant metastasis occurs late in the disease progression.

Explanation: ### **Explanation** **1. Why Option C is False (The Correct Answer):** Contrary to the statement, **lower lip carcinoma actually has a better prognosis** compared to most other oral cavity cancers. This is primarily because the lower lip is an anatomically external site, allowing for **early detection** by the patient. Furthermore, the lymphatic drainage of the lower lip is relatively predictable (Submental and Submandibular nodes), and the incidence of occult metastasis is lower than that of the tongue or floor of the mouth. The 5-year survival rate for early-stage lip cancer is excellent, often exceeding 90%. **2. Analysis of Other Options:** * **Option A (Smoking):** This is **True**. Chronic irritation from tobacco (both smoking and chewing) and alcohol are major risk factors. Additionally, UV radiation (sun exposure) is a primary driver for lower lip SCC. * **Option B (Lower Lip Predominance):** This is **True**. Approximately 90% of lip carcinomas occur on the lower lip. This is attributed to its greater exposure to solar radiation compared to the upper lip. (Note: Upper lip cancers are rarer but often more aggressive). * **Option D (Distant Metastasis):** This is **True**. Lip carcinoma is locally invasive. Metastasis typically occurs first to regional lymph nodes; distant spread (to lungs or bone) is a late event in the disease progression. ### **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Histology:** Squamous Cell Carcinoma (SCC) is the most common type for the **lower lip**, while Basal Cell Carcinoma (BCC) is more common on the **upper lip**. * **Lymphatic Drainage:** The central part of the lower lip drains to **Level Ia (Submental)** nodes, while the lateral parts drain to **Level Ib (Submandibular)** nodes. * **Staging Tip:** Lip cancer is staged under "Oral Cavity" cancers in the AJCC TNM system. * **Treatment:** Surgical excision with 5-10mm margins is the gold standard. For defects involving >1/3 of the lip, reconstructive flaps (e.g., Karapandzic or Abbe-Estlander) are required.

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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