Neck

Neck Indian Medical PG Question 1: N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:

• A. Metastasis in a lymph node >6 cm (Correct Answer)
• B. Metastasis in lymph nodes >2 cm
• C. Metastasis in lymph nodes >5 cm
• D. None of the options

Neck Explanation: ***Metastasis in a lymph node >6 cm*** - **N3a disease** in head and neck cancer staging (AJCC 8th edition) specifically refers to metastasis in a single lymph node larger than 6 cm in greatest dimension **without extranodal extension (ENE)**. - This applies to oral cavity, oropharynx (HPV-negative), hypopharynx, and larynx cancers. - **Note:** N3 staging also includes **N3b** (metastasis in any node with clinically overt ENE), but this question specifically asks about N3a criteria. *Metastasis in lymph nodes >2 cm* - Lymph nodes in the 2-3 cm range typically fall within **N1 or N2a categories**, depending on laterality and number of involved nodes. - **N3a disease** requires a single lymph node to exceed 6 cm in greatest dimension without ENE. *Metastasis in lymph nodes >5 cm* - A lymph node between 3-6 cm is usually classified as **N2 disease** (N2a if single ipsilateral ≤6 cm, N2b if multiple ipsilateral ≤6 cm, N2c if bilateral or contralateral ≤6 cm). - To be classified as **N3a**, the lymph node must be **>6 cm** without extranodal extension. *None of the options* - This option is incorrect because the first option accurately describes the size criterion for **N3a TNM staging** in head and neck tumors according to AJCC 8th edition guidelines. - While N3 staging has two subcategories (N3a and N3b), the size criterion of >6 cm correctly defines N3a disease.

Neck Indian Medical PG Question 2: All of the following are branches of the external carotid artery except?

• A. Superior thyroid artery
• B. Transverse cervical artery (Correct Answer)
• C. Ascending pharyngeal artery
• D. Superficial temporal artery

Neck Explanation: ***Transverse cervical artery*** - The **transverse cervical artery** is a branch of the **thyrocervical trunk**, which itself originates from the **subclavian artery**, not the external carotid artery. - It supplies muscles in the neck and shoulder region. *Superior thyroid artery* - The **superior thyroid artery** is typically the first branch of the **external carotid artery**. - It supplies the **thyroid gland** and adjacent structures in the neck. *Ascending pharyngeal artery* - The **ascending pharyngeal artery** is the only **medial branch** of the **external carotid artery**. - It supplies the **pharynx**, prevertebral muscles, and middle ear. *Superficial temporal artery* - The **superficial temporal artery** is one of the **two terminal branches** of the **external carotid artery**, forming in the parotid gland. - It supplies the scalp in the temporal region and is palpable anterior to the ear.

Neck Indian Medical PG Question 3: Surgical treatment for a 40-years old lady with 3 x 3 cm. papillary carcinoma thyroid with level III enlarged lymph nodes is :

• A. Total thyroidectomy with radical neck dissection
• B. Total thyroidectomy with post-operative radio-iodine ablation
• C. Total thyroidectomy with excision of involved nodes
• D. Total thyroidectomy with functional neck dissection (Correct Answer)

Neck Explanation: ***Total thyroidectomy with functional neck dissection*** - For **papillary thyroid carcinoma** with **level III lymph node involvement**, the standard approach is **total thyroidectomy** with **therapeutic lateral neck dissection** (functional/modified radical neck dissection). - **Level III nodes** are part of the **lateral compartment** (levels II-IV), requiring formal **compartment-oriented dissection** rather than selective node excision for adequate oncological clearance. *Total thyroidectomy with excision of involved nodes* - **"Excision of involved nodes"** is not standard terminology in thyroid surgery and **"berry-picking"** individual nodes is generally not recommended for therapeutic purposes. - **Compartment-oriented dissection** is preferred over selective node removal as it provides better oncological outcomes and staging accuracy. *Total thyroidectomy with radical neck dissection* - **Radical neck dissection** involves removal of cervical lymph node levels I-V along with the **sternocleidomastoid muscle**, **internal jugular vein**, and **spinal accessory nerve**. - This extensive procedure is reserved for cases with **extensive extranodal extension** or when these structures are directly involved, causing significant morbidity. *Total thyroidectomy with post-operative radio-iodine ablation* - **Radioiodine ablation** is an **adjuvant therapy** used after thyroidectomy to destroy remaining thyroid tissue and microscopic disease. - This option doesn't address the **surgical management** of enlarged lymph nodes, which is specifically what the question asks about.

Neck Indian Medical PG Question 4: Which levels of cervical lymph nodes are included in a modified radical neck dissection?

• A. I-IV
• B. I-V (Correct Answer)
• C. I-III
• D. II-VI

Neck Explanation: ***I-V*** - A modified radical neck dissection typically removes lymph nodes from levels **I through V**, along with preservation of one or more non-lymphatic structures (sternocleidomastoid muscle, internal jugular vein, or spinal accessory nerve). - This extensive dissection addresses potential metastasis to these node groups from head and neck cancers, crucial for adequate oncologic clearance while aiming for functional preservation. *I-III* - This limited dissection would likely be insufficient for many head and neck cancers, as spread often extends beyond level III. - It would miss potential metastases in the lower jugular and posterior triangle nodes, increasing the risk of recurrence. *I-IV* - This dissection omits **level V**, which includes the posterior triangle nodes, a common site for metastatic spread, especially for cancers of the oropharynx, hypopharynx, and thyroid. - Excluding level V would be considered an incomplete radical or modified radical neck dissection in many clinical scenarios. *II-VI* - This option incorrectly excludes lymph nodes at **level I** (submental and submandibular nodes), which are critical draining sites for many oral cavity cancers. - Including level VI (anterior compartment nodes) is typically part of a central compartment neck dissection, often performed for thyroid cancer, but is usually not part of a standard modified radical neck dissection for other head and neck primaries unless specifically indicated.

Neck Indian Medical PG Question 5: You evaluate an 18 yrs old male who sustained a right sided cervical laceration during a gang fight. Which of the following is a relative rather than an absolute indication for neck exploration?

• A. Dysphonia
• B. Expanding hematoma
• C. Pneumothorax (Correct Answer)
• D. Dysphagia

Neck Explanation: ***Pneumothorax*** - A pneumothorax, while concerning, can often be managed with a **chest tube** insertion without immediate surgical exploration, making it a relative indication. - Its presence suggests potential compromise to structures in the neck/chest but doesn't always mandate direct surgical wound exploration as a first step. *Dysphonia* - **Hoarseness or difficulty speaking** after a neck injury suggests potential direct laryngeal, tracheal, or recurrent laryngeal nerve injury, warranting exploration to assess and repair. - This symptom implies a direct compromise of the **airway or critical nerves**, making exploration more immediate. *Expanding hematoma* - An **expanding hematoma** indicates active, potentially life-threatening bleeding and/or mass effect, which can compromise the airway or blood supply to the brain. - This is an **absolute indication for immediate surgical exploration** to control hemorrhage and prevent airway obstruction. *Dysphagia* - **Difficulty swallowing** post-neck trauma suggests injury to the pharynx or esophagus. - Such injuries carry a significant risk of **mediastinitis** or sepsis if not promptly identified and repaired via surgical exploration.

Neck Flashcard 1 of 5

Question: From lateral to medial the three major structures within carotid sheath includes the _____ vein, vagus nerve, and the common carotid arteryBonus: what is in the fascia?

Answer: internal jugular

Neck Flashcard 2 of 5

Question: What are the 5 branches of ECA given off in the carotid triangle?_____ (Anterior branches).Ascending pharyngeal (medial branch)Occipital artery (posterior branch)

Answer: Superior thyroid, lingual, and facial artery

Neck Flashcard 3 of 5

Question: Nerve supply of larynx _____ the level of vocal cords is by recurrent laryngeal nerve which is a branch of the Vagus nerve.

Answer: below

Neck Flashcard 4 of 5

Question: The contents of the carotid sheath from lateral to medial are _____.

Answer: Internal jugular vein, Common carotid artery, Vagus nerve

Neck Flashcard 5 of 5

Question: Boundaries of the carotid triangle:_____ is formed by thyrohyoid, hyoglossus muscle, middle constrictor, and inferior constrictor.

Answer: Floor