Head and Neck Surgery — MCQs

Head and Neck Surgery Indian Medical PG Practice Questions and MCQs

Question 51: Which of the following is NOT a feature of submucosal cleft palate?

A. Bifid uvula
B. Notched hard palate
C. Lip pits (Correct Answer)
D. Zona pellucida

Explanation: ### Explanation **Submucosal Cleft Palate (SMCP)** is a specific type of clefting where the underlying palatal musculature (levator veli palatini) fails to fuse in the midline, despite the overlying mucous membrane remaining intact. **Why "Lip pits" is the correct answer:** Congenital **lip pits** (paramedian pits on the lower lip) are the hallmark feature of **Van der Woude Syndrome**, which is the most common syndromic cause of orofacial clefts. While they are associated with cleft lip and palate, they are **not** a diagnostic feature of the submucosal cleft palate itself. **Analysis of incorrect options (The Classic Triad):** The diagnosis of SMCP is clinical and is classically defined by **Calnan’s Triad**: 1. **Bifid Uvula (Option A):** The most common and visible sign; the uvula appears split or "fish-tailed." 2. **Notched Hard Palate (Option B):** A palpable V-shaped notch at the posterior border of the hard palate due to the absence of the posterior nasal spine. 3. **Zona Pellucida (Option D):** A thin, translucent bluish area in the midline of the soft palate caused by the diastasis (separation) of the palatal muscles, leaving only a thin layer of mucosa. **High-Yield Clinical Pearls for NEET-PG:** * **Velopharyngeal Insufficiency (VPI):** Patients with SMCP often present with hypernasal speech and nasal regurgitation of fluids because the maloriented muscles cannot effectively close the nasopharynx. * **Management:** Not all cases require surgery. Treatment (Pharyngoplasty or Furlow Palatoplasty) is indicated only if the patient develops speech defects or significant VPI. * **Gutzmann’s Test:** A clinical test used to detect the hypernasality associated with cleft palate.

Question 52: Injury of which nerve most commonly leads to vocal cord paralysis?

A. Recurrent laryngeal (Correct Answer)
B. External laryngeal
C. Internal laryngeal
D. Superior laryngeal

Explanation: ### Explanation **1. Why Recurrent Laryngeal Nerve (RLN) is Correct:** The **Recurrent Laryngeal Nerve (RLN)**, a branch of the Vagus nerve (CN X), provides motor innervation to all intrinsic muscles of the larynx except for the cricothyroid. Most importantly, it supplies the **posterior cricoarytenoid**, which is the sole abductor of the vocal cords. Injury to the RLN—most commonly during thyroidectomy or parathyroidectomy—results in the loss of abduction, leading to vocal cord paralysis. Unilateral injury causes hoarseness, while bilateral injury can lead to acute airway obstruction (stridor). **2. Why Other Options are Incorrect:** * **External Laryngeal Nerve:** This is a branch of the Superior Laryngeal Nerve (SLN). It supplies only the **cricothyroid muscle** (the "tenser" of the vocal cord). Injury leads to a loss of high-pitched voice and vocal fatigue, but not paralysis of the cord itself. * **Internal Laryngeal Nerve:** This is purely **sensory**. It supplies the laryngeal mucosa above the vocal cords. Injury results in loss of the cough reflex, increasing the risk of aspiration, but does not affect cord mobility. * **Superior Laryngeal Nerve (SLN):** This nerve divides into the internal and external branches. While its injury affects voice quality and sensation, the actual "paralysis" (immobility) of the vocal cord is specifically a hallmark of RLN damage. **3. Clinical Pearls for NEET-PG:** * **Most common nerve injured in Thyroidectomy:** External Laryngeal Nerve (due to its proximity to the Superior Thyroid Artery). * **Nerve most commonly causing Vocal Cord Paralysis:** Recurrent Laryngeal Nerve (due to its proximity to the Inferior Thyroid Artery). * **Semon’s Law:** In progressive RLN lesions, abductor fibers are injured before adductor fibers; thus, the cord initially assumes a median/paramedian position. * **Left vs. Right RLN:** The Left RLN is longer and loops around the Arch of Aorta, making it more susceptible to injury from thoracic pathologies (e.g., lung cancer, aortic aneurysm) compared to the Right RLN, which loops around the Subclavian Artery.

Question 53: What is described as a cystic compressible, translucent swelling in the posterior triangle of the neck?

A. Cystic hygroma (Correct Answer)
B. Branchial cyst
C. Thyroglossal cyst
D. Dermoid cyst

Explanation: ### Explanation **Cystic Hygroma** is a congenital malformation of the lymphatic system (lymphangioma) resulting from the failure of lymphatics to connect with the venous system. It typically presents at birth or in early childhood. **Why it is the correct answer:** * **Location:** It most commonly occurs in the **posterior triangle** of the neck (behind the sternocleidomastoid). * **Physical Characteristics:** It is a **cystic, soft, and compressible** mass. Because it contains clear lymph and has thin walls, it is classically **brilliantly translucent** (positive transillumination test). It is often described as a "brilliant" swelling because it lacks a solid capsule and infiltrates tissue planes. **Why the other options are incorrect:** * **Branchial Cyst:** Typically located in the **upper third of the neck**, along the anterior border of the sternocleidomastoid (anterior triangle). It is usually opaque (not translucent) due to cholesterol crystals in the fluid. * **Thyroglossal Cyst:** Found in the **midline** of the neck, usually at the level of the hyoid bone. Its hallmark is that it moves upward on protrusion of the tongue. * **Dermoid Cyst:** Usually occurs in the **midline** (submental region). It has a "doughy" consistency and is **not translucent** because it contains sebaceous material and hair. **High-Yield Clinical Pearls for NEET-PG:** * **Association:** Frequently associated with chromosomal abnormalities like **Turner syndrome** and Down syndrome. * **Complications:** Sudden increase in size usually indicates **hemorrhage** into the cyst or infection. * **Management:** Surgical excision is the gold standard, though sclerotherapy (e.g., OK-432, Bleomycin) is an alternative for macrocystic lesions. * **Cross-illumination:** If a torch is pressed against one side, the entire swelling lights up, confirming its fluid-filled, thin-walled nature.

Question 54: Which one of the following is the most common tumor to produce metastasis to cervical lymph nodes?

A. Glottic carcinoma
B. Nasopharyngeal carcinoma (Correct Answer)
C. Carcinoma base of tongue
D. Carcinoma lip

Explanation: **Explanation:** The correct answer is **Nasopharyngeal Carcinoma (NPC)**. This is due to the rich submucosal lymphatic network of the nasopharynx and the fact that NPC often remains clinically silent in its early stages. Consequently, **75–90% of patients** present with cervical lymphadenopathy at the time of diagnosis. It is the most common primary site for an "unknown primary" presenting as a neck mass. Metastasis is often bilateral and typically involves Level II, III, and V (posterior triangle) nodes. **Analysis of Options:** * **Glottic Carcinoma:** The vocal cords have **sparse to no lymphatic drainage**. Therefore, glottic cancer rarely metastasizes to the neck in early stages (T1/T2), making it the least likely among the options to present with nodal spread. * **Carcinoma Base of Tongue:** While this area is rich in lymphatics and has a high rate of nodal metastasis (approx. 60–70%), it is statistically less frequent than Nasopharyngeal Carcinoma. * **Carcinoma Lip:** This typically spreads to Level I (submental/submandibular) nodes. It generally has a better prognosis and a lower rate of early metastasis (approx. 10%) compared to oropharyngeal or nasopharyngeal sites. **High-Yield Clinical Pearls for NEET-PG:** * **Rouviere’s Node:** The most superior lateral retropharyngeal node, often the first site of spread in NPC. * **Troisier’s Sign:** Enlargement of the left supraclavicular node (Virchow’s node), usually indicating intra-abdominal malignancy (e.g., Gastric CA), not primary head and neck CA. * **EBV Association:** Nasopharyngeal carcinoma (specifically Type II and III) is strongly associated with the **Epstein-Barr Virus**. * **Rule of 80:** In non-thyroid neck masses in adults, 80% are neoplastic, and of those, 80% are malignant (mostly metastatic Squamous Cell Carcinoma).

Question 55: A 35-year-old male presents with squamous cell carcinoma of the tongue, staged as T2N0M0. What is the most likely treatment for this patient?

A. Suction-assisted oropharyngeal tumor resection with neck dissection (Correct Answer)
B. Level 1-2 lymph node excision
C. Level 1-5 lymph node dissection
D. Level 1-6 lymph node dissection

Explanation: **Explanation:** The management of **T2N0M0 Squamous Cell Carcinoma (SCC) of the tongue** involves two primary goals: local control of the primary tumor and prophylactic management of the neck. 1. **Why Option A is Correct:** For T2 lesions (2–4 cm), the standard of care is wide local excision of the primary tumor combined with an **Elective Neck Dissection (END)**. Even in a clinically N0 neck, the risk of "occult metastasis" (microscopic spread) in tongue SCC exceeds 20%. Therefore, observation is not recommended. The neck dissection typically performed is a **Supraomohyoid Neck Dissection (SOHND)**, covering Levels I, II, and III, which are the primary drainage sites for the oral tongue. 2. **Why the Other Options are Incorrect:** * **Option B:** Level 1–2 excision is inadequate. Tongue cancers frequently skip to Level 3 (deep cervical nodes); thus, a formal SOHND (Levels 1–3) is the minimum requirement. * **Option C:** Level 1–5 dissection (Radical or Modified Radical Neck Dissection) is generally reserved for clinically N+ (node-positive) disease. It is overly morbid for a N0 neck. * **Option D:** Level 6 (anterior compartment) nodes are primarily involved in thyroid, laryngeal, or hypopharyngeal cancers, not oral tongue SCC. **High-Yield Clinical Pearls for NEET-PG:** * **Depth of Invasion (DOI):** In the latest AJCC 8th edition, DOI is a critical prognostic factor. A DOI >4 mm in a T1/T2 N0 neck is a strong indication for elective neck dissection. * **Most common site:** The lateral border of the tongue is the most common site for oral SCC. * **Lymphatic Drainage:** The tip of the tongue drains to Level 1 (Submental), while the lateral borders drain to Level 2 and 3. * **Treatment of choice for T1N0:** Wide local excision; END is considered if DOI >4mm.

Question 56: What is the main causative agent of Ludwig's angina?

A. Anaerobic streptococci
B. Aerobic streptococci (Correct Answer)
C. Staphylococci
D. Legionella infection

Explanation: **Explanation:** Ludwig’s angina is a rapidly spreading, potentially life-threatening **cellulitis** of the submandibular, sublingual, and submental spaces. **1. Why Aerobic Streptococci is correct:** The infection is typically polymicrobial, involving both aerobic and anaerobic flora from the oral cavity. However, **Alpha-hemolytic streptococci (Aerobic/Viridans group)** are the most frequently isolated organisms. These bacteria initiate the infection, creating a synergistic environment that allows anaerobes to flourish. In the context of NEET-PG, while it is a mixed infection, **Streptococci** (specifically aerobic/viridans) is recognized as the primary causative agent. **2. Analysis of Incorrect Options:** * **Anaerobic streptococci (A):** While anaerobes like *Bacteroides* and *Peptostreptococcus* are often present due to the gangrenous nature of the infection, they are usually secondary to the initial aerobic streptococcal invasion. * **Staphylococci (C):** *Staphylococcus aureus* is occasionally isolated, particularly in immunocompromised patients or following trauma, but it is not the "main" or most common cause compared to Streptococci. * **Legionella infection (D):** *Legionella* typically causes atypical pneumonia (Legionnaires' disease) and is not associated with deep neck space infections or dental pathology. **Clinical Pearls for NEET-PG:** * **Source:** The most common cause is a **dental infection** (usually the 2nd or 3rd mandibular molar). * **Clinical Features:** Characterized by "woody" or brawny edema of the neck, tongue protrusion (elevation of the floor of the mouth), and absence of fluctuance (it is a cellulitis, not an abscess). * **Management Priority:** The most critical step is **Airway Management**, followed by IV antibiotics and surgical decompression if necessary. * **Key Sign:** Look for "Hot potato voice" and drooling in clinical vignettes.

Question 57: During extraction of an upper first molar, the mesiobuccal root is missing and is suspected to have been pushed into the maxillary sinus. Which of the following flaps cannot be used to close an oroantral fistula?

A. Buccal flap
B. Palatal flap
C. Tongue flap
D. Mucous flap (Correct Answer)

Explanation: **Explanation:** The clinical scenario describes an **Oroantral Fistula (OAF)**, a pathological communication between the oral cavity and the maxillary sinus, commonly occurring after the extraction of maxillary molars (especially the first molar) due to the proximity of the roots to the sinus floor. **Why "Mucous flap" is the correct answer:** The term "mucous flap" is non-specific and does not refer to a recognized surgical technique for OAF closure. Successful closure of a fistula requires a **pedicled flap** (a flap with its own blood supply) that can be transposed or advanced to cover the defect. A simple "mucous flap" without a robust submucosal vascular supply or sufficient thickness would lack the structural integrity and blood supply necessary to heal over an antral opening, leading to breakdown and recurrence. **Analysis of Incorrect Options:** * **A. Buccal Flap (Rehrmann’s Flap):** This is the most common technique. It involves a broad-based sliding advancement of the buccal mucosa. It is simple but may result in a reduction of the vestibular depth. * **B. Palatal Flap:** Usually based on the **greater palatine artery**. It provides a thick, resilient tissue (keratinized mucosa) which is excellent for closing larger or recurrent fistulas. * **C. Tongue Flap:** This is a distant pedicled flap used for very large defects or when local (buccal/palatal) tissues have failed. It is a two-stage procedure where the tongue is sutured to the defect and detached later. **Clinical Pearls for NEET-PG:** * **Small openings (<2mm):** Usually heal spontaneously with a blood clot. * **Moderate openings (2-6mm):** Require figure-of-eight sutures and gelatin sponges. * **Large openings (>6mm):** Require surgical flap closure (Buccal or Palatal). * **Gold Standard:** The **Buccal Fat Pad (BFP) flap** is often considered highly effective due to its rich vascularity and low failure rate. * **Radiology:** The "Water’s View" (Occipitomental) is the preferred X-ray to visualize the maxillary sinus.

Question 58: Sialosis refers to:

A. Bilateral parotitis
B. Sjogren's syndrome
C. Non-inflammatory parotid enlargement (Correct Answer)
D. Bilateral salivary duct ectasia

Explanation: **Explanation:** **Sialosis** (also known as Sialadenosis) is a non-inflammatory, non-neoplastic, recurrent, and typically painless enlargement of the salivary glands, most commonly affecting the **parotid glands** bilaterally. **1. Why Option C is Correct:** The underlying pathophysiology involves **demyelinating polyneuropathy** of the autonomic nervous system, leading to dysregulation of acinar protein secretion. This causes an accumulation of secretory granules within the acinar cells, resulting in hypertrophy (enlargement) without the presence of inflammatory cells or infection. **2. Why Other Options are Incorrect:** * **Option A (Bilateral parotitis):** Parotitis implies an inflammatory or infectious process (e.g., Mumps), characterized by pain, fever, and tenderness, which are absent in sialosis. * **Option B (Sjogren’s syndrome):** This is an autoimmune condition characterized by lymphocytic infiltration and destruction of the glands, leading to xerostomia (dry mouth) and keratoconjunctivitis sicca. * **Option D (Bilateral salivary duct ectasia):** This refers to the dilation of the ducts, often seen in chronic obstructive sialadenitis, whereas sialosis involves acinar hypertrophy. **High-Yield Clinical Pearls for NEET-PG:** * **Associated Conditions:** Sialosis is frequently linked to systemic metabolic or endocrine disorders, most notably **Diabetes Mellitus**, **Chronic Alcoholism**, and **Malnutrition** (e.g., Bulimia or Kwashiorkor). * **Clinical Presentation:** Characterized by "soft, doughy" bilateral swelling that is non-tender. * **Sialogram Appearance:** Often shows a **"leafless tree"** appearance due to the compression of small ducts by hypertrophied acini. * **Management:** Primarily focuses on treating the underlying systemic cause (e.g., glycemic control or nutritional rehabilitation).

Question 59: What are the predisposing factors for the development of oral carcinoma?

A. Smoking
B. Alcohol
C. Syphilis
D. All of the above (Correct Answer)

Explanation: **Explanation:** Oral squamous cell carcinoma (OSCC) is a multifactorial disease primarily driven by chronic irritation and exposure to carcinogens. The correct answer is **"All of the above"** because each factor listed plays a distinct role in the pathogenesis of oral malignancy. 1. **Smoking:** Tobacco contains potent carcinogens like nitrosamines and polycyclic aromatic hydrocarbons. These induce DNA damage and mutations in the p53 tumor suppressor gene. In the Indian context, smokeless tobacco (chewing) is equally significant, often leading to "Gum-Boots" or "Snuff-dipper's" carcinoma. 2. **Alcohol:** While not a direct carcinogen, alcohol acts as a solvent, increasing the permeability of the oral mucosa to tobacco-derived carcinogens. Its metabolite, acetaldehyde, is also mutagenic. The synergistic effect of smoking and alcohol increases the risk of oral cancer by nearly 15-fold. 3. **Syphilis:** Historically, tertiary syphilis is associated with "chronic interstitial glossitis." The resulting atrophic changes on the dorsum of the tongue create a precancerous state, predisposed to malignant transformation. **Clinical Pearls for NEET-PG:** * **Most common site:** In India, it is the **buccal mucosa** (due to betel nut chewing); globally, it is the **lower lip** and **lateral border of the tongue**. * **Precancerous lesions:** Leukoplakia (white patch), Erythroplakia (red patch - higher malignant potential), and Oral Submucous Fibrosis (OSMF). * **Plummer-Vinson Syndrome:** Associated with post-cricoid carcinoma and oral cancer due to iron deficiency causing mucosal atrophy. * **Field Cancerization:** This concept explains why patients with one oral primary are at high risk for synchronous or metachronous tumors in the upper aerodigestive tract.

Question 60: Frey syndrome is associated with surgery of which gland?

A. Parotid (Correct Answer)
B. Pituitary
C. Parathyroid
D. Adrenal

Explanation: **Explanation:** **Frey Syndrome** (also known as **Auriculotemporal Syndrome**) is a common complication following surgery of the **Parotid gland**, most frequently after a superficial parotidectomy. **Mechanism:** The condition is caused by the **aberrant regeneration** of nerve fibers. During parotid surgery, the **auriculotemporal nerve** (which carries parasympathetic fibers to the parotid gland and sympathetic fibers to the sweat glands of the overlying skin) is severed. During healing, the parasympathetic fibers mistakenly regrow to innervate the sympathetic receptors of the sweat glands and subcutaneous blood vessels. Consequently, a stimulus intended to produce saliva (like smelling or eating food) results in localized **gustatory sweating** and flushing. **Analysis of Incorrect Options:** * **Pituitary:** Surgery (Transsphenoidal) may lead to Diabetes Insipidus or CSF rhinorrhea, but not gustatory sweating. * **Parathyroid:** Surgery involves the neck but does not involve the auriculotemporal nerve; complications include hypocalcemia or recurrent laryngeal nerve injury. * **Adrenal:** Surgery (Adrenalectomy) is abdominal/retroperitoneal; complications include hemorrhage or adrenal insufficiency. **Clinical Pearls for NEET-PG:** * **Diagnosis:** Confirmed by the **Minor’s Starch-Iodine Test** (the area turns blue-black upon sweating). * **Treatment:** Topical anticholinergics (Glycopyrrolate) or **Botulinum toxin (Botox) injections** (most effective). * **Prevention:** Interposition of barriers like the SMAS flap or Sternocleidomastoid muscle flap during surgery. * **Nerve involved:** Auriculotemporal nerve (a branch of the Mandibular nerve, V3).

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

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Surgical Approaches to the Neck

Practice Questions

Neck Dissection Techniques

Practice Questions

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