Head and Neck Surgery Practice Questions

Q: Ohngren's classification is used for:

Maxillary sinus carcinoma. ***Maxillary sinus carcinoma*** - Ohngren's classification is a staging system specifically used for **maxillary sinus carcinomas**. - It divides the maxillary sinus into **anteroinferior** and **posterosuperior** parts, using a plane passing through the medial canthus and angle of the mandible. *Nasopharyngeal carcinoma* - This type of cancer is staged using the **AJCC (American Joint Committee on Cancer) TNM classification system**, not Ohngren's. - Nasopharyngeal carcinoma has distinct risk factors and presentation, often involving the **Epstein-Barr virus**. *Oropharyngeal carcinoma* - Staging for oropharyngeal carcinoma also utilizes the **AJCC TNM classification**, which has specific considerations for **HPV status**. - It typically affects areas like the **tonsils, base of tongue, and soft palate**. *Tongue carcinoma* - Squamous cell carcinoma of the tongue is staged using the **AJCC TNM system**, focusing on tumor size, nodal involvement, and distant metastasis. - Prognosis depends heavily on the **depth of invasion** and lymph node status.

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: 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: Treatment of choice for a temporal bone fracture with facial nerve palsy is:

Nerve decompression. ***Nerve decompression*** - This is the treatment of choice for **traumatic facial nerve palsy** secondary to a **temporal bone fracture**, especially if the palsy is immediate, severe, or progressive. - Decompression aims to relieve pressure on the nerve caused by edema or bony impingement within its canal, preventing irreversible damage. *Facial nerve repair* - **Direct nerve repair** is considered only if there is a **transection or complete laceration** of the facial nerve, which is usually evident on high-resolution imaging or during exploration. - It involves reconnecting the severed nerve ends and is not applicable when the nerve is simply compressed by swelling or fracture fragments. *Fracture stabilization* - **Stabilizing the temporal bone fracture** is important for overall healing and preventing further injury, but it does not directly address the compression of the facial nerve within its bony canal. - While necessary for skeletal integrity, it is not the primary treatment for the neurological deficit itself. *Observation and monitoring* - **Observation and monitoring** may be appropriate for **delayed-onset facial nerve palsies** or very mild palsies, where the chance of spontaneous recovery is higher. - However, for immediate or severe palsy, especially with evidence of nerve compression, this approach risks permanent nerve damage.

Q: All of the following may be acceptable operative approaches to the management of thoracic outlet syndrome, except:

Thoracoplasty. ***Thoracoplasty*** - **Thoracoplasty** is a surgical procedure that involves **removing ribs** to *reduce the size of the thoracic cavity*, primarily used for lung collapse therapy in tuberculosis or to manage chronic empyema. - It is **not a treatment for thoracic outlet syndrome (TOS)**, as TOS involves compression of neurovascular structures in the thoracic outlet, not a need for lung volume reduction. *Scalenectomy* - A **scalenectomy**, involving the partial or complete removal of the **anterior and/or middle scalene muscles**, is a common surgical approach for TOS. - These muscles can **compress the brachial plexus** and subclavian artery, and their removal helps decompress the neurovascular bundle. *Excision of a cervical rib* - A **cervical rib** is a congenital anomaly that can **compress the brachial plexus** and subclavian artery, leading to TOS symptoms. - Its surgical **excision is a direct and effective** treatment for TOS caused by this anatomical variant. *First rib resection* - **First rib resection**, performed via various approaches (transaxillary, supraclavicular, infraclavicular), is a **primary surgical treatment for TOS**. - The first rib can **compress the subclavian artery, subclavian vein, or brachial plexus**, and its removal creates more space in the thoracic outlet.

Q: What is the most common source of hemorrhage during tonsillectomy?

Injury to tonsillar branch of facial artery. ***Injury to tonsillar branch of facial artery*** - The **tonsillar branch of the facial artery** is the most significant arterial supply to the palatine tonsil and is located superficially, making it highly susceptible to injury during tonsillectomy. - Its relatively large caliber and direct tonsillar supply contribute to it being the **most common source of hemorrhage** during the procedure. *Injury to tonsillar branch of lingual artery* - The **tonsillar branch of the lingual artery** provides some supply to the tonsil, but it is typically less significant and less common as a source of hemorrhage compared to the facial artery branch. - This vessel usually penetrates the superior constrictor muscle to reach the tonsil, making it less directly exposed during standard tonsillectomy dissection. *Injury to external palatine vein* - The **external palatine vein** (paratonsillar vein) is often a source of venous bleeding due to its superficial location and direct drainage of the tonsil. - While it can cause significant bleeding, arterial hemorrhage, particularly from the facial artery branch, is generally considered more common and profuse. *Injury to tonsillar branch of ascending pharyngeal artery* - The **tonsillar branch of the ascending pharyngeal artery** supplies the tonsil but is usually a smaller vessel and is located deeper or more posterior to the tonsil. - Due to its anatomical position, it is less frequently injured during the typical tonsillectomy dissection planes compared to the tonsillar branch of the facial artery.

Q: Which of the following changes in voice is not produced as a result of external laryngeal nerve injury post thyroidectomy?

Hoarseness. ***Hoarseness*** - **Hoarseness** is primarily caused by injury to the **recurrent laryngeal nerve (RLN)**, which innervates most intrinsic laryngeal muscles responsible for vocal cord adduction and abduction. - An external laryngeal nerve (ELN) injury affects the **cricothyroid muscle**, leading to less tension on the vocal cords, but typically not frank hoarseness. *Voice fatigue* - Injury to the external laryngeal nerve (ELN) weakens the **cricothyroid muscle**, which is responsible for tensing and elongating the vocal cords. - This weakness leads to greater effort required to maintain vocal quality, resulting in **voice fatigue**. *Inability to sing at higher ranges* - The **cricothyroid muscle**, innervated by the ELN, is crucial for increasing vocal cord tension. - Increased tension is necessary for adjusting vocal pitch and reaching **higher frequencies** or notes. *Poor volume and projection* - The cricothyroid muscle's role in vocal cord tension contributes to the efficiency of vocal fold vibration. - Reduced tension due to ELN injury can lead to decreased **vocal power and projection**.

Q: Most definitive treatment for large symptomatic acoustic neuroma is

Surgery. ***Surgery*** - **Surgical resection** is the most definitive treatment for **large, symptomatic acoustic neuromas** (typically >3 cm), especially those causing **mass effect** on the brainstem and cerebellum. - It aims for **complete tumor removal** to alleviate symptoms (hearing loss, facial nerve dysfunction, brainstem compression) and prevent further neurological compromise. - Surgical approaches include **translabyrinthine**, **retrosigmoid**, or **middle cranial fossa** approaches depending on tumor size and hearing status. *Steroids* - **Steroids** may be used to manage acute symptoms like **edema** or inflammation associated with the tumor, but they are not a definitive treatment. - They do not address the underlying tumor growth or remove the mass. - Used only as **temporary symptomatic relief** or perioperative adjunct. *Radiotherapy* - **Stereotactic radiosurgery** (Gamma Knife, CyberKnife) is effective for **small to medium-sized tumors** (<3 cm) with good tumor control rates. - For **large tumors**, radiotherapy is **insufficient** as it only aims to **control tumor growth** rather than remove the mass, and cannot provide immediate decompression. - Large tumors with mass effect require **surgical decompression** for definitive management. *Anti-neoplastic drugs* - **Anti-neoplastic drugs** (chemotherapy) are generally **ineffective** against acoustic neuromas, which are **benign vestibular schwannomas**. - They are typically reserved for malignant tumors or specific genetic syndromes (e.g., bevacizumab in NF2-related schwannomas), but not for standard sporadic acoustic neuromas. - Chemotherapy is **not a definitive treatment** for these benign tumors.

Question 1

Ohngren's classification is used for:

Accepted Answer

Maxillary sinus carcinoma

Answer

Nasopharyngeal carcinoma

Answer

Oropharyngeal carcinoma

Answer

Tongue carcinoma

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

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 5

Treatment of choice for a temporal bone fracture with facial nerve palsy is:

Accepted Answer

Nerve decompression

Answer

Facial nerve repair

Answer

Fracture stabilization

Answer

Observation and monitoring

Question 6

All of the following may be acceptable operative approaches to the management of thoracic outlet syndrome, except:

Accepted Answer

Thoracoplasty

Answer

Excision of a cervical rib

Answer

First rib resection

Answer

Scalenectomy

Question 7

What position of the patient facilitates the maximum depression of the soft palate?

Accepted Answer

The patient is seated upright with the head straight.

Answer

The patient is in a lateral position.

Answer

The patient is in a prone position.

Answer

The patient is in a supine position with the head slightly extended.

Question 8

What is the most common source of hemorrhage during tonsillectomy?

Accepted Answer

Injury to tonsillar branch of facial artery

Answer

Injury to tonsillar branch of lingual artery

Answer

Injury to external palatine vein

Answer

Injury to tonsillar branch of ascending pharyngeal artery

Question 9

Which of the following changes in voice is not produced as a result of external laryngeal nerve injury post thyroidectomy?

Accepted Answer

Hoarseness

Answer

Inability to sing at higher ranges

Answer

Poor volume and projection

Answer

Voice fatigue

Question 10

Most definitive treatment for large symptomatic acoustic neuroma is

Accepted Answer

Surgery

Answer

Steroids

Answer

Radiotherapy

Answer

Anti-neoplastic drugs

Head and Neck Surgery — MCQs

Head and Neck Surgery — MCQs

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