Head and Neck Surgery

Head and Neck Surgery Indian Medical PG Question 1: In an accident case, after the arrival of medical team, all should be done in early management except;

• A. Glasgow coma scale
• B. Check BP (Correct Answer)
• C. Stabilization of cervical vertebrae
• D. Check Respiration

Head and Neck Surgery Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.

Head and Neck Surgery Indian Medical PG Question 2: A 55 year old male came with history of hoarseness of voice for which direct laryngoscopy was done and the lesion was biopsied to detect squamous cell carcinoma. He now requires investigation to detect extent of cartilage involvement, imaging of pre and paraglottic spaces and any extension to deep neck structures. Most appropriate investigation of choice will be:

• A. MRI (Correct Answer)
• B. CT Scan
• C. Repeat direct laryngoscopy under general anaesthesia
• D. Endo Ultrasound

Head and Neck Surgery Explanation: ***MRI*** - **MRI** is superior for evaluating **cartilage involvement** (especially thyroid cartilage), pre-epiglottic, and paraglottic space invasion due to its excellent **soft tissue contrast**. - It also helps in assessing **deep neck invasion**, perineural spread, and for identifying disease recurrence after radiation therapy. *CT Scan* - While CT can show bone and cartilage calcification, its ability to differentiate subtle **cartilage invasion** and **soft tissue involvement** in the pre-epiglottic and paraglottic spaces is inferior to MRI. - It involves **ionizing radiation** and may not provide as detailed information regarding the extent of soft tissue and marrow invasion. *Repeat direct laryngoscopy under general anaesthesia* - This is an **invasive procedure** primarily used for direct visualization, biopsy, and staging of superficial lesions or for therapeutic interventions. - It is not effective for evaluating the **depth of invasion** or spread to **deep neck structures**. *Endo Ultrasound* - **Endoscopic ultrasound (EUS)** is primarily used for evaluating gastrointestinal and sometimes tracheobronchial lesions for depth of invasion and nodal staging. - It is **not the primary imaging modality** for assessing the extent of laryngeal squamous cell carcinoma, especially for cartilage invasion or deep neck structures.

Head and Neck Surgery Indian Medical PG Question 3: What is Galen's anastomosis?

• A. Recurrent laryngeal nerve and external laryngeal nerve
• B. Internal laryngeal nerve and recurrent laryngeal nerve (Correct Answer)
• C. None of the options
• D. Recurrent laryngeal nerve and sympathetic trunk

Head and Neck Surgery Explanation: ***Internal laryngeal nerve and recurrent laryngeal nerve*** - **Galen's anastomosis** (also known as **ansa Galeni**) is the connection between the **internal laryngeal nerve** (a sensory branch of the superior laryngeal nerve) and the **recurrent laryngeal nerve** (motor branch of the vagus nerve). - This anastomosis occurs in the **laryngeal mucosa** and allows for communication between these two important nerves. - The **internal laryngeal nerve** provides **sensory innervation** to the larynx above the vocal cords, while the **recurrent laryngeal nerve** provides **motor innervation** to most intrinsic laryngeal muscles (except cricothyroid). - This anastomosis is clinically significant in understanding the complex innervation patterns of the larynx. *Recurrent laryngeal nerve and external laryngeal nerve* - While both nerves are branches of the vagus nerve and innervate laryngeal structures, this connection does not constitute **Galen's anastomosis**. - The recurrent laryngeal nerve innervates intrinsic laryngeal muscles (except cricothyroid), while the external laryngeal nerve innervates the **cricothyroid muscle** and is motor in nature. *None of the options* - This option is incorrect because the correct definition of **Galen's anastomosis** is provided in the first option. *Recurrent laryngeal nerve and sympathetic trunk* - While there may be sympathetic contributions to laryngeal innervation, this does not represent **Galen's anastomosis**. - The sympathetic trunk provides autonomic innervation but the specific named anastomosis refers to the connection between the internal laryngeal and recurrent laryngeal nerves.

Head and Neck Surgery Indian Medical PG Question 4: 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

Head and Neck Surgery 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.

Head and Neck Surgery Indian Medical PG Question 5: Identify the investigation being carried out in the image.

• A. Fluoroscopy
• B. X-ray after alkali ingestion
• C. X-ray after acid ingestion
• D. Barium Swallow (Correct Answer)

Head and Neck Surgery Explanation: ***Barium Swallow*** - The image shows a contrast material, characteristic of **barium**, flowing through the esophagus, captured as a sequence of X-ray images, which is the definition of a barium swallow study. - This **dynamic imaging** allows for evaluation of swallowing function and esophageal motility. *Fluoroscopy* - While a barium swallow uses **fluoroscopy** to visualize the movement of barium, fluoroscopy itself is the technique, not the specific investigation being performed. The image depicts the result of a specific type of fluoroscopic examination. - Fluoroscopy is a general term for real-time X-ray imaging, whereas "Barium Swallow" specifies the type of study being done on the upper GI tract. *X-ray after alkali ingestion* - This scenario would typically involve viewing the effects of **corrosive injury** to the esophagus, which would appear as mucosal damage, narrowing, or perforation. The image does not show these features; instead, it shows smooth passage of contrast. - There is no visible evidence of an acute or chronic injury pattern consistent with **alkali ingestion**, which often leads to severe burns or strictures. *X-ray after acid ingestion* - Similar to alkali ingestion, acid ingestion also causes **corrosive injury**, typically affecting the stomach more severely than the esophagus. The image does not demonstrate these pathological changes. - The smooth, unobstructed flow of contrast in multiple frames is indicative of normal esophageal function rather than the sequelae of corrosive ingestion.

Head and Neck Surgery Flashcard 1 of 5

Question: The commonest complication of Caldwell Luc operation is _____

Answer: infra orbital nerve injury

Head and Neck Surgery Flashcard 2 of 5

Question: In subtype 1 of modified radical neck dissection, what structures are preserved?_____

Answer: spinal accessory nerve

Head and Neck Surgery Flashcard 3 of 5

Question: _____ operation is used for squamous cell carcinoma of the oral cavity

Answer: Commando

Head and Neck Surgery Flashcard 4 of 5

Question: _____ position is used in tonsillectomy, adenoidectomy and tracheostomy

Answer: Rose's

Head and Neck Surgery Flashcard 5 of 5

Question: Ethmoidal vessels are exposed in the medial wall of the orbit by an external ethmoid (_____) incision.

Answer: Lynch