MCQ Compile PDF

Disclaimer : Dear all, The answers are based on our readings, discussion, textbooks and extensive googling. Please forgive us if some answers are incorrect. We wish you best of luck in exams! Amy Oon Grace Ong Jolynn Jean Lee Eng Siang S. Darmma HEAD & NECK 1. Regarding the first branchial cleft...

Disclaimer : Dear all, The answers are based on our readings, discussion, textbooks and extensive googling. Please forgive us if some answers are incorrect. We wish you best of luck in exams! Amy Oon Grace Ong Jolynn Jean Lee Eng Siang S. Darmma HEAD & NECK 1. Regarding the first branchial cleft fistula: a) It is found along the border of sternocleidomastoid muscle F - this is for type 2 branchial cyst. for type 1 : They are often in close relation to the parotid gland, facial nerve, external auditory canal and the anterior neck near the angle of the mandible b) The tract ascends along the carotid sheath posteriorly to the internal carotid artery F this is for 3 or 4th branchial cleft fistula as it opens into pyriform fossa c) It is associated with the facial nerve T - work classification work type 1 is rarer and lateral to FN work type 2 is more common and is medial / in between fn branches d) It goes into the tonsillar pillar F tonsilar pillar opening is a/w type 2 e) It opens into the pyriform sinus F - branchial cleft 3rd and 4th 2. Radio-iodine ablation post thyroidectomy is a treatment of: a) Papillary carcinoma T b) Follicular carcinoma T c) Medullary carcinoma F - cause from parafollicular c cells therefore does not take up RAI d) Hurthle carcinoma T Hurthle cell neoplasms originate in thyroid follicles from follicular cells (hence they were initially grouped with follicular thyroid tumors) and are characterized by the presence of Hurthle cells, which are eosinophilic oxyphilic cells. Radioactive iodine (RAI) is commonly used in the adjuvant setting for high- risk features like tumor size >2 cm, cervical lymph node metastases, positive margins, microvascular invasion, or postoperative thyroglobulin levels are more than 1 ng/mL. It is estimated that only around 10% of patients with Hurthle cell carcinoma lesions take up radioiodine; hence responses to treatment with RAI are much lower in these patients when compared to other types of thyroid carcinomas e) Anaplastic carcinoma F 3. Aetiology of oropharyngeal carcinoma includes: a) Marijuana smoking T b) Dietary deficiency of vitamin C T - They include vitamins A (retinol), C (AA), and E (α-tocopherol); carotenoids (β-carotene); potassium; and selenium (38–43). β-carotene, retinol, retinoids, vitamin C (AA), and vitamin E (α-tocopherol) are antioxidants that are essential in reducing free radical reactions that can cause DNA mutations, changes in enzymatic activity, and lipid peroxidation of cellular membranes. c) Syphilis infection T - HPV infection d) Human immunodeficiency virus T - HIV more in burkitt lymphoma unless want to consider lymphoma in oropharyngeal ca??? e) Human papilloma virus T 4. Complication of parotidectomy includes: a) Anaesthesia over the angle of mandible T- over earlobe and angle of mandible b) Temporomandibular joint become prominent T after removal of parotid tissue can cause sunken cheek c) Dysgeusia F d) Gustatory flushing T frey syndrome e) Salivary fistula T 5. Regarding nasopharyngeal carcinoma: a) Migration from high incidence to low incidence areas prevent its development in high risk individual F - genetic knows no geography b) Laryngopharyngeal reflux is a risk factor F c) Haplotypes of the human leukocyte antigen (HLA) loci on the short arm of chromosome 6 has increased risk T The Human leukocyte antigen (HLA) complex is located on Chromosome 6p21.3 and it has been repeatedly documented to be associated with the prevalence of NPC d) Human papilloma virus type 6,11 is an association F EBV e) There is risk of second aerodigestive tract primary tumour T 6. Regarding cervical lymph nodes metastases: a) Survival is worse for metastases beyond the first echelon of lymphatic drainage T b) Survival is good for nodes in supraclavicular area F any neck nodes decrease cervical rate 50% c) Midline nodes are considered ipsilateral nodes T d) Direct extension of the primary tumour into lymph nodes is classified as metastases T According to the 8th UICC Classification, the direct extension of the primary tumor into LNs is classified as the LN metastasis. e) When involved the contralateral nodes are considered as terminal stage Dr Julius say dont answer cause what do you mean by terminal?? palliative? stage 4? C) 7. Regarding granulomatous diseases of the parotid gland a) Sarcoidosis is bilateral T Parotid sarcoidosis is presented as a persistent asymptomatic or painful, diffuse, non-nodular parotid swelling. Sarcoidosis of the parotid gland is more often bilateral, with onset slightly more common in women in their third or fourth decades b) Sarcoidosis presents with progressive cranial nerve involvement T The most common neurologic manifestation of sarcoidosis is cranial neuropathy secondary to nerve granulomas, raised intracranial pressure, or granulomatous meningitis. The facial nerve is the most frequently affected cranial nerve. The paralysis is usually temporary and unilateral but it can also be bilateral in a simultaneous or sequential manner. The optic nerve appears to be the second most commonly involved cranial nerve c) Cat scratch disease is due to Gram positive bacillus F Bartonella henselae is a fastidious gram-negative bacterium d) Actinomycosis occurs after oral trauma T e) Heerfordt’s disease is caused by tuberculosis F Sarcoidosis - uveoparotid fever Constellation of findings in Heerfordt’s syndrome Fever Painless parotid enlargement Cranial nerve involvement Uveitis Definitive diagnosis of parotid sarcoidosis is cumulatively based on the patient’s medical history, clinical examination, and the presence of non-caseating granulomas.1 An accurate radiological study is essential for further assessment. Because the parotid glands are superficially located structures, high- frequency ultrasound evaluation is a first-line diagnostic modality. 8 Other imaging modalities such as sialography or computed tomography are useful options. The majority of patients diagnosed with sarcoidosis are not disabled by the illness,2 and sarcoidosis of the parotid gland has shown to be self-limited in many. The decision to provide treatment should thus be weighted for the risks and benefits that may follow. The conventional therapy of choice for sarcoidosis is either no treatment at all, due to its spontaneous remission, or corticosteroids. The use of corticosteroids is the most common medical therapy when organ symptomatology is severe.9 To avoid steroid toxicity, other steroid-sparing or steroid-substituting agents may be therapeutic: methotrexate, azathioprine, cyclosporine, or hydroxychloroquine.9 However, corticosteroid therapy demonstrated no clear-cut benefit for patients of persistent, chronic sarcoidosis of the parotid gland. Patients that do not respond to steroid therapy may be responsive to infliximab, a monoclonal antibody against tumor necrosis factor-alpha(TNF-α).9 The level of circulating TNF-α is increased in patients of sarcoidosis and is also found in the sarcoid nodules.9 Infiximab acts to block the interaction between TFN-α and its receptor bindind sites. Parotid gland swelling is not an uncommon chief complaint, but the consideration of sarcoidosis in its differential diagnosis is not common. The involvement of sarcoidosis in parotid glands is extremely rare. Moreover, it is even rarer for parotid glands to be the primary manifestation site of sarcoidosis. Knowledge of the clinical symptomatology of sarcoidosis and the presence of bilateral parotid gland swelling could be a significant diagnostic clue.9 8. Regarding cervicofacial actinomycosis: a) Severe periodontitis is a feature T b) Suppurative pneumonia is a complication T Pulmonary infections are primarily due to the aspiration of oral and GI secretions c) The invaded adjacent tissue becomes soft F become hard as it becomes lumpy jaw syndrome Lumpy jaw is a disease that produces permanent hard swellings on the jaw bones. Once an infection is established, bacterial by-products begin breaking down the bone. In response to the bone infection, the body tries to repair itself by creating new bone d) Sulphur grains are found in the discharge T e) Actinomycosis israeli is aerobic organism F anaerobic Actinomycosis is a rare subacute to chronic infection caused by the gram-positive filamentous non-acid fast anaerobic to microaerophilic bacteria, Actinomyces. The infection is usually a granulomatous and suppurative infection. The chronic form has multiple abscesses that form sinus tracts and are associated with sulfur granules. About 70% of infections are due to either Actinomyces israelii or Actinomyces gerencseriae. Actinomyces are nonspore‑forming, filamentous, and facultative gram positive anaerobes. They are normal constituents of the oral flora within gingival crevices and tonsillar crypts and are particularly prevalent in periodontal pockets, dental plaques, and on carious teeth. A retrospective study done in the University of Cologne reported the incidence of actinomycotic infection affecting the mandible (53.6%), cheek (16.4%), chin (13.3%), submaxillary ramus and angle (10.7%), maxilla (5.7%), and temporomandibular joints(0.3%).[4,5] About half of the patients diagnosed with actinomycosis have a history of local trauma resulting in mucosal breakdown. Actinomyces bacteria cannot penetrate healthy tissue, and mucosal breakdown is a prerequisite for infection. Poor dental hygiene, caries, oral trauma, dental extraction, and an immunocompromised status are considered to be important antecedents. Moreover, as reported in the present case reports, the first patient had a history of dental extraction supporting the prerequisite, mucosal breakdown for the infection and the second patient had a history of local trauma followed by infection of the wound. A hallmark of cervicofacial actinomycosis is the tendency to spread without regard for anatomical barriers, including fascial planes or lymphatic drainage, and the development of multiple sinus tracts. A malignant neoplasm may also result in an enhancing solid mass, but the lesion usually has a relatively well-defined margin, without substantial inflammatory change in the adjacent soft tissue unless it is complicated by infection. The lack of lymphadenopathy despite a large, aggressive‑appearing mass with an inflammatory change may be a helpful clue in differentiating cervicofacial actinomycosis from a malignancy. Diagnostic imaging technologies such as CT and magnetic resonance imaging usually yield nonspecific findings, contributing only to define radiological features of the mass and its involvement in adjacent soft tissues. Culture and isolation of the bacteria make the definitive diagnosis of the disease. However, Actinomyces growth is very difficult even on appropriate anaerobic media with the recovery from culture being 2 levels, >3cm- will need radiotherapy If +ve margin, + extracapsular will need to add chemotherapy “occult primary carcinoma in head and neck” is the presentation of metastatic neck lymphadenopathy without the development of a primary lesion within a subsequent 5-year period. However, the diagnosis is one of exclusion and consequently depends upon the diligence exercised in the search for a primary tumor. Failure to identify an occult primary has been attributed to either spontaneous regression of the primary tumor, autoimmune destruction or possibly accelerated tumor progression. The term carcinoma of unknown primary origin (CUP) should be used if no evidence of primary tumor is found after adequate clinical examination, fibreoptic endoscopy and conventional radiological investigations. 58. Regarding pharyngeal pouch: a) It origin in between the middle constrictor and inferior constrictor muscles F between cricopharyngeus and thyropharyngeus both components of inferior constrictor b) Pathophysiology of the lesion include spasm of the cricopharyngeus muscle T hence one of the treatment is botox injection c) Dohlman operation is an endoscopic excision of the pouch F endoscopic division of bar d) Barium swallow findings are diagnostic T e) Carcinoma developing in the pouch is rare T  Pharyngeal pouch seen at endoscopy with a transparent distal attachment. It is a false diverticulum cause content mucosa and submucosa only 59. Regarding skin grafting in head and neck region a) A full thicknesss skin graft consiste of the entire thickness of dermis T b) Split thickness skin grafts revascularise more slowly than full thickness grafts F c) A full thickness grafted site need not be mobilized F d) They are useful in covering exposed mandible F e) The split skin graft has very little application in reconstruction F A split-thickness skin graft (STSG), by definition, refers to a graft that contains the epidermis and a portion of the dermis, which is in contrast to a full-thickness skin graft (FTSG) which consists of the epidermis and entire dermis. Most commonly, STSG autografts are taken from the lateral thigh, as well as trunk, as these sites are both aesthetically hidden, as well as easy to harvest from due to their broad surfaces. Split-thickness skin grafts classify according to their thickness into thin STSGs (0.15 to 0.3mm), intermediate STSGs (0.3 to 0.45mm), and thick STSGs (0.45 to 0.6mm). Because split-thickness skin graft donor sites retain portions of the dermis, including dermal appendages, the donor site can regrow new skin in 2 to 3 weeks. Thus, donor sites can be used more than once after appropriate healing has taken place, which makes STSGs versatile in burn surgery and large wounds where there are limited donor sites. The advantages and disadvantages of STSGs are best highlighted by comparison with FTSGs. Considerations of proper skin graft selection should include graft take, contracture of skin graft, donor site morbidity, aesthetic match, and durability. Graft Take: The thicker a skin graft, the more metabolically active it is, and the worse is it's nutrient diffusion. FTSGs and thick STSG's require more robust recipient wound beds than thin STSGs. Thick grafts should be avoided in unhealthy wound beds such as chronic ulcers. Contracture: All skin grafts undergo primary and secondary contractures. Primary contracture is the immediate reduction in the size of skin graft after it has been harvested, caused by passive recoil of elastin fibers in the dermis. As FTSGs have a greater amount of dermis, primary contracture is more significant in FTSG than STSG. Secondary contracture is the shrinkage of the skin graft in the wound bed over time, caused by myofibroblasts. Secondary contracture is  greater for STSGs than FTSGs, as the additional dermis in FTSGs is resistant to the pull of myofibroblasts. Clinically, STSG placement should not be in aesthetically sensitive areas that could become deformed with contractures such as around the eyelids, face, and mouth. Donor Site Morbidity: The multipotent stem cells responsible for STSG donor site reepithelialization primarily reside in the hair follicles. By preserving portions of the dermis and thereby hair follicles, STSG donor sites regrow new skin and are reusable. Thin STSGs have the least donor site morbidity and regrow new skin the fastest. Full-thickness skin grafts involve excision of the entire thickness of skin, and thus adnexal structures, necessitating primary closure. Aesthetic Match: Skin grafts should ideally match the recipient bed in color, texture, and overall appearance. Full-thickness skin grafts commonly provide an appropriate color match, whereas STSGs are more likely to be hypo/hyperpigmented. Additionally, the meshing of STSGs significantly alters the aesthetics of STSGs. Durability: As the dermis provides strength and viscoelastic properties to the skin, the consideration of dermal thickness is essential for each specific wound. For example, thick STSGs or FTSG are common choices to cover mechanically demanding areas of the body, including the palms, soles, and joints, whereas thin STSGs do not withstand such forces as well. Disadvantages of STSGs compared to other reconstructive techniques include at times poor resemblance to surrounding recipient site skin (color match and texture if meshed), high susceptibility to trauma, poor sensation of the recipient site, need for anesthesia/surgery (compared to secondary intention healing), and prolonged need for wound care of both the donor and recipient sites (compared to flap closure). As mentioned above, STSGs do not have their own blood supply, so they must rely on the underlying wound bed for nutrients and blood supply. Presuming a stable, healthy, and well-vascularized wound bed, skin grafts take occurs in three commonly described steps: 1. Imbibition: ○ The skin graft passively absorbs oxygen and nutrients from the wound bed. During this phase, the skin graft is ischemic and survives on diffusion alone until reestablishing graft vasculature. The graft is pale/white during this time. Split-thickness skin grafts can tolerate up to 4 days of ischemia. 2. Inosculation: ○ A vascular network is established between the cut vessels on the underside of the skin graft and the capillary beds in the wound bed, establishing a vascular connection. The graft becomes pink at this point. Inosculation typically occurs at around 48 hours after graft placement. 3. Revascularization ○ Several hypotheses exist regarding the exact mechanism of revascularization. The neovascularization theory is of new vessel ingrowth into the graft from the recipient wound bed. The endothelial cell ingrowth theory suggests that endothelial cells proliferate and slide from the recipient site by following pre-existing vascular basal lamina as structure, with graft endothelial cells eventually degrading. Clinically, skin grafts are secured into place and often bolstered until postoperative day 5 to 7 to allow the skin graft to go through the above steps, ensuring the best skin graft take. Split-thickness skin grafts are typically adherent after 5 to 7 days upon completion of the stages of wound healing. Once the graft has integrated into the wound bed, it undergoes a maturation process that takes over one year to complete. Absolute contraindications: wounds with an active infection, active bleeding, or known cancer. Wounds with exposed bone, tendon, nerve, or blood vessel without appropriate vascular layer. Relative contraindications: wounds over joints or key anatomic landmarks in which contraction would reduce mobility and/or aesthetics (i.e., wrist, elbow, eyelid), and previously irradiated wounds. ADDED BY ES 60. The following are examples of pedicled myocutaneous flaps used for reconstruction in head and neck surgery a) Rectus abdominis flap T inferior epigastric b) Trapezius flap T transverse cervical artery, the dorsal scapular artery, and the posterior intercostal arterial branches. c) Latissimus dorsi flap T thoracodorsal artery d) Deltopectoral flap Fasciocutaneous internal mammary artery e) Forehead flap F cutaneous pedicled supratrochlear and supraorbital 61. The following statements regarding neck dissection are true a) Supraomohyoid neck dissection involves the removal of level I and II lymph nodes. False. Removal of level I,II,III b) The sternomastoid muscle is preserved in modified radical neck dissection type III. True. Type III preserves SCM, IJV ans SAN c) Level I lymph nodes are preserved in lateral neck dissection. True. lateral neck dissection is level 2,3,4 d) MacFee incision should be used when post-operative radiotherapy is considered. False. e) The prevertebral fascia should be excised with the lymph node bearing tissues in neck dissection. False. Prevertebral fascia is not excised 62. The following statements are true regarding thyroid gland malignancies a) A thyroid nodule appearing as hot on radioisotope iodine uptake scan rules out malignancy. False. As it represents active thyroid tissue and malignance should be cold nodule Nodules that produce excess thyroid hormone — called hot nodules — show up on the scan because they take up more of the isotope than normal thyroid tissue does. Hot nodules are almost always noncancerous. In some cases, nodules that take up less of the isotope — called cold nodules — are cancerous b) Follicular carcinoma has a peak incidence in early adulthood. False Follicular thyroid cancer tends to occur in an older population when compared with other differentiated thyroid cancers. Its peak incidence is between ages 40 and 60 years, as compared with papillary thyroid cancer incidence peaking earlier, between the ages of 30 to 50 years c) Patients on post operative follow up should have thyroxine replacement to suppress TSH secretion. True. to inhibit cell proliferation d) Raised serum thyroglobulin levels serves as a marker for medullary carcinoma. False. Marker for PTC and follicular as they are throglobulin producing cells and medullary are calcitonin producing cells e) Anaplastic carcinoma can mimic lymphoma histologically. T ADDED BY ES 63. The following are true of post-operative care in head and neck surgery a) Oral feeding is commenced within 7 to 10 days in laryngectomised patients. True b) Following a laryngectomy, the serum calcium level is reviewed the following morning. True c) Following a laryngectomy the serum thyroxine level is reviewed the following morning. False. Half life of thyroxine is 1/52 d) Drains are removed 3days post-surgery. True e) Following gastric pull-up, the requirement of calcium is greater. T Added by ES - Calcium absorption impaired 64. The following test are helpful in diagnosing Sjogren syndrome a) FBC- True b) Rheumatoid factor. True c) Liver function test. False d) Serum folate. True e) Sublabial biopsy. True. for minor salivary gld biops Laboratory test results may indicate the following: Elevated erythrocyte sedimentation rate (ESR) Anemia Leukopenia Eosinophilia Hypergammaglobulinemia Presence of antinuclear antibodies (ANAs), especially anti-Ro and anti-La Presence of rheumatoid factor (RF) Presence of anti–alpha-fodrin antibody (reliable diagnostic marker of juvenile Sjögren syndrome) Creatinine clearance may be diminished in up to 50% of patients Biopsy Minor salivary gland biopsy currently is the best single test to establish a diagnosis of Sjögren syndrome. In this procedure, an incision is made on the inner lip, and some minor salivary glands are removed for examination. In patients with a possible diagnosis of this disease but with severe extraglandular symptoms, a lip biopsy is often performed to firmly establish the diagnosis of Sjögren syndrome. Obtaining the biopsy sample from below normal-appearing mucosa is important in order to avoid false-positive results. At least 4 salivary gland lobules should be obtained for analysis. 65. Regarding risk of head and neck carcinoma a) Exposure to chromate increases risk for laryngeal cancer. True occupational exposure to Cr(VI) can cause lung cancer, nose and nasal sinus cancer in humans. Cr(VI) is suspected to cause stomach cancer and laryngeal cancer in humans b) Nitrosamines is related to adenocarcinoma. False it is related to NPC c) HPV 11 is found in 40% of squamous cell carcinoma. False. it is HPV 16 d) EBV antibody titre of IgA is elevated in NPC. True e) DNA hypomethylation predispose to salivary gland malignancy. True Two types of methylation changes are usually observed : Hypermethylation of the CpG islands and global hypomethylation in a variety of tumors. DNA hypomethylation has been associated with the activation of oncogenes and chromosomal instability leading to overexpression of the oncogenes, while DNA hypermethylation is associated with the repression of tumor suppressor genes (TSG) and genomic instability. DNA methylation also plays an important role in tumor initiation and progression 66. Regarding facial nerve in parotid gland surgery a) Local anaesthesia cause facial nerve paresis. T b) Facial vein is reflected inferiorly to protect the nerve. False. this is for submandibular gland excision The Hayes-Martin manoeuvre involves ligation of the posterior facial vein and superior reflection of the investing fascia below the mandible to preserve the marginal mandibular nerve c) The nerve encountered lateral to posterior belly of digastric muscle. False. encountered over the same plane Added by ES - The facial nerve trunk lies approximately 1 cm above and parallel to the upper border of the digastric muscle near its insertion at the mastoid tip. d) Nerve monitoring induced neuropraxia. true. If overstimulation e) Hypoglossal jump anastomosis is an option for intraoperative reconstruction. true 67. Pharyngeal pouch a) Originates from dehiscence in the inferior constrictor muscles. True. Between the thyropharygeus and cricopharyngeus muscle b) Is Associated With Tuberculous Infection. False. Associated with old age c) Presents with dyspnea. false. presents with dysphagia d) Is excised endoscopically with Dohlman procedure. F Dohlman procedure: the partition wall (septum) between the esophagus and the pouch is divided by diathermy through endoscope e) Has high tendency for malignant change. False. Malignant change 0.3% 68. Glomus tumour is mostly a) Hypervascular. True b) Exhibit aggressive growth characteristics. F - Non-encapsulated and highly vascular - Slow growing but locally invasive (bone erosion)s c) Present with synchronous lesions. F - 10% with synchronous tumor (multicentric) - 10% familial - 10% risk of malignancy 5% Mets Agressive Secreting 10% Familial Malignant extradrenal d) Exhibit clinically evident hypersecretion of cathecolamines. False only 5% secrete cathecolamine e) Originated in the jugular bulb in the temporal bone. true 69. Following are responsible for poor prognosis in oral cancer: a) Minor salivary gland tumour. T b) Perineural spread. True c) Mandibular invasion. T Added by ES - mandible involvement increase T staging d) Well differentiated tumour. false e) Coexistent coronary artery disease. true 70. In thyroid surgery a) Recurrent laryngeal nerve is easily injured at the thyrohyoid membrane. F easily injured at inferior pedicle. Thyrohyoid is superior pedicle b) Parathyroid gland is preserved in medullary thyroid carcinoma. true During a total thyroidectomy for MTC, normal parathyroid glands should be preserved in situ on a vascular pedicle. If all normal parathyroid glands are resected or if none appear viable at the termination of the procedure, slivers of a parathyroid gland should be transplanted into the sternocleidomastoid muscle in patients with sporadic MTC, MEN2B, or MEN2A and a RET mutation rarely associated with HPTH. In patients with MEN2A and a RET mutation associated with a high incidence of HPTH, the parathyroid tissue should be transplanted in a heterotopic muscle bed c) Inferior thyroid artery is identified above the internal laryngeal nerve. F ITA does not reach so high up d) Joll’s triangle is used as a landmark for recurrent laryngeal nerve identification. F this is beahr triangle e) The non-recurrent laryngeal nerve is found on the left side.F A nonrecurrent laryngeal nerve (NRLN) is a rare anatomical variation in which the nerve enters the larynx directly from the cervical vagus nerve, without descending to the thoracic level. It has been reported in 0.3-0.8% of the population on the right side, being extremely rare on the left side (0.004%) 71. Condition that predisposes parotid gland abscess includes a) Duct stenosis T- b) Duct stones T- c) Dehydration T- d) Immunocompromised T- e) Edentulous F- 72. The following are true of oropharyngeal carcinoma a) Epstein Barr virus subtype play a role F- The prevalence of viruses in laryngeal and oropharyngeal carcinomas is presented in Table III. HPV was detected in a total of 32.5% of patients, including 22.5% with HPV type 16; in four cases (10%) other types were detected, i.e. 59, 45, and 68. HPV was detected in laryngeal carcinoma (36%) more often than in oropharyngeal carcinoma (26.7%). However, this difference was not statistically significant. EBV was identified in 57.5% of the studied samples, including 60% of laryngeal carcinomas and 53.3% of oropharyngeal carcinomas. HHV-1 was identified in six cases (7.5%), CMV in eight cases (10%). HHV-1 and CMV were more often detected in laryngeal than in oropharyngeal cancer. This difference was not statistically significant. Co- infection with one or more viruses was detected in 30% of cases. Co-infection with EBV and HPV (15%) was detected most frequently. Co-infection between other viruses was identified: EBV with CMV in 7.5%; HPV with CMV in 5%; HPV with CMV and EBV was detected in one case. The frequency of detection of HPV DNA increased with the age of patients, i.e. in patients under 50 years of age it was 8.3%, and in the group of patients aged over 70 years it was 83.3.3% (Table III). On the other hand, EBV was most frequently detected in the age group of those under 50 years, i.e. at 66.7%. The prevalence of HHV-1 and CMV was the highest in patients under 50 years of age and for both viruses it was 16.7%. b) Surgery or radiation alone are equally effective for T1 and T2 tumour T- c) In stage T4b (AJCC 2002) the tumours invade the pterygoid plates T- 4a: involves cortical bone or involves the inferior alveolar nerve , FOM , skin of face 4b; pterygoid plates, masseter, skull base, encases carotid artery d) Bilateral involvement of hypoglossal nerve is classified as functional inoperable T e) The spindle cell variant is clinically similar to squamous cell carcinoma F Spindle cell carcinoma is rare variant of SCC-aggressive and rapidly progressive neoplasm Unlike other oral cancers, the SpCC has a unique clinical appearance with distinct macroscopic growth. The majority of SpCC presents as polypoid, pedunculated, and exophytic. Extensive ulceration, necrosis, and pain are common [6,9,12–14]. Whenever SpCC is suspected, the biopsy should involve the base of the lesion where tumor cell foci tend are located; otherwise, surface biopsy canbe non-diagnostic. Typically, the tumor grows very rapidly, and early metastasis is a common [15,16]. Noticeable differences exist in the prognosis and overall survival of SpCC compared to SCC. These authors believe an aggressive surgical resection should be considered as the primary mode of intervention. The 5-years survival rate for oral SpCC is 30%, and the incidence of metastasis found to be 36% [2,16]. The clinical staging and superficial or invasive findings influence the effectiveness of surgical treatment [2,15,16]. Amy add The Epstein-Barr virus (EBV), traditionally linked etiologically with infectious mononucleosis (IM), endemic Burkitt lymphoma (BL) and nasopharyngeal carcinoma (NPC) has in recent years been associated with a host of other conditions EBV infects approximately 95% of the world’s adult population and, after primary infection, the individual remains a lifelong carrier. The oropharynx is the primary site of infection and is believed to be the site for virus replication. HPV-positive OPSCC is associated with lower T stage and higher N stage compared to HPV-negative OPSCC Early nodal involvement can be attributed to the lack of subepithelial connective tissue layers underneath the tonsillar crypt epithelium. Thus, tumor cells from the layer of basal cells move to the neck lymph nodes before the primary lesion has grown large enough to be detected on a routine examination. For this reason, up to 40% of HPV-positive OPSCCs are diagnosed with ipsilateral neck involvement Oropharynx p16 negative TNM TX: primary tumor cannot be assessed Tis: carcinoma in situ T1: tumor ≤2 cm in greatest dimension T2: tumor >2 cm and ≤4 cm T3 ○ tumor >4 cm, or ○ tumor extension to lingual surface of epiglottis T4: moderately or very advanced ○ T4a: moderately advanced local disease in which tumor invades any of the following: larynx (except lingual surface of epiglottis) extrinsic muscles of the tongue medial pterygoid muscle hard palate mandible ○ T4b: very advanced local disease in which tumor encases carotid artery or invades any of the following: lateral pterygoid muscle pterygoid plates lateral nasopharynx skull base Human papillomavirus (HPV)-mediated oropharyngeal (p16+) cancer staging refers to TNM staging of squamous cell carcinomas of the oropharynx that test positive for p16, an immunohistochemical proxy for HPV infection. Nodal metastases of p16+ squamous cell carcinoma without an identified primary tumor are also staged under this system. This classification is new in the 8th edition of the American Joint Committee on Cancer Staging Manual, published in 2017 1-3. Primary tumor (T) T0: no primary identified T1: tumor ≤2 cm in greatest dimension T2: tumor >2 cm and ≤4 cm  T3 ○ tumor >4 cm, or ○ tumor extension to lingual surface of epiglottis T4: moderately advanced local disease in which tumor invades any of the following or beyond: ○ larynx (except lingual surface of epiglottis) ○ extrinsic muscles of the tongue ○ medial pterygoid muscle ○ hard palate ○ mandible Regional lymph node (N) Clinical (cN) criteria Clinical criteria apply to all patients before surgical treatment, by using information from physical examination, imaging, and/or needle biopsies. NX: regional lymph nodes cannot be assessed cN0: no regional lymph node metastasis cN1: one or more ipsilateral lymph nodes, all ≤6 cm cN2: contralateral or bilateral lymph nodes, all ≤6 cm cN3: lymph node(s) >6 cm 73. The following are true of hypopharyngeal tumours a) The Arnold nerve accounts for referred otalgia T- THROAT: Referred otalgia is via the Vagus nerve (CNX). Innervation of the infero-posterior tympanic membrane is Arnold’s nerve Innervation of the pyriform fossa is the internal laryngeal nerve These branches converge with the main nerve trunk before entering the brain causing otalgia. b) CT scan is adequate to evaluate the primary tumour F- c) Plummer-vinson disease is associated with pyriform sinus subsite F- Postcricoid carcinoma is uncommon in general but observed in certain groups at risk (patients with the Plummer–Vinson syndrome). These tumors spread submucosally most often toward the cervical esophagus. Because tumor growth is mainly submucosal, the true extent only becomes apparent with axial or sagittal MR images d) Submucosal spread is more common in tumours located in the superior Hypopharynx Added by ES - UKM answer F The incidence of submucosal tumor extensions in hypopharyngeal cancer is high (58%), but most (67%) of them can be detected grossly at operation. The presence of submucosal tumor extension does not adversely affect the survival and tumor recurrence rates.Studies have reported that tumor margins are usually infiltrating (80%) but can be pushing (20%). Unsuspected submucosal spread can extend beyond 1 cm of visible tumor margins. Skip lesions or multifocal areas of disease are not unusual. e) The incidence of level V lymph nodes metastases is between 20-30% F- 1-5% 74. In laryngeal cancer a) Infiltration into paraglottic space will lead to transglottic involvement T- Transglottic cancer of the larynx crosses the laryngeal ventricle and involves both the vestibular and vocal folds. It has been described to spread within the paraglottic space (PGS) b) Metastases to submandibular gland is rare T- Metastases of level I of the neck and the submandibular gland are extremely rare in cases of laryngeal and/or hypopharyngeal carcinoma. The risk of facial or hypoglossal nerve injury does not justify the dissection of level I and of the submandibular gland in this type of tumour. c) The clinical staging underestimates when compared to pathological examination T- The clinical staging of laryngeal carcinoma showed: high accuracy in staging was on glottic tumours (83.3%), especially T1 glottic tumours (100%),(small and superficial lesions), and lower accuracy in staging of supraglottic and transglottic tumors (61.9%) , (55.6% ) respectively.Underestimation of all tumors was 31.4% d) Endoscopic laser partial laryngectomy is an alternative treatment for T3 tumour T- In recent years, an increasing number of centers have reported experience with TLM in advanced laryngeal disease. Although data are primarily obtained from retrospective patient cohorts, there appear to be significant data to support utilization of TLM in the setting of advanced laryngeal cancer Use of TLM as a primary treatment modality for advanced laryngeal tumors is likely to remain controversial in the near future. In the absence of level I data demonstrating equivalence for T3 disease TLM is unlikely to replace chemo-EBRT as the primary treatment paradigm. e) Hypothyroidism post radiation is rare F-Hypothyroidism following radiation therapy (RT) for treatment of Head and Neck Cancer (HNC) is a common occurrence. Rates of hypothyroidism following RT for Early Stage Laryngeal Squamous Cell Carcinoma (ES-LSCC) are among the highest 75. Pertaining to the principles of chemotherapy in the management of head and neck cancer a) Cisplatin is ototoxic T- Cisplatin is a widely used chemotherapeutic agent with a high degree of ototoxicity and an average incidence of over 60% (Karasawa and Steyger, 2015) b) Carboplatin has higher risk of nephrotoxicity as compared to cisplatin F- cisplatin is associated with a higher rate of nausea, vomiting, nephrotoxicity, ototoxicity, while carboplatin has a higher risk of myelosupresssion and neurotoxicity Carboplatin causes dose-limiting and cumulative myelosuppression, characterised by frequent and severe thrombocytopenia, granulocytopenia and anaemia. Likewise, cisplatin is associated with several cumulative and irreversible toxicities, including dose-dependent renal tubule toxicity and neurotoxicity c) Combination chemotherapy for recurrent disease has little impact on survival rate F- The use of concurrent chemoradiotherapy (CCRT) for head and neck cancers has been shown to be effective and safe in the older patients with cancer. A meta-analysis by Pignon et al. showed an improvement in overall survival by 4.5% at 5 years and an absolute benefit for concurrent CCRT of 6.5% when compared to radiation alone, however this benefit was only in patients below 70 years of age. Data from the Indian subcontinent on CCRT in the elderly is scanty. d) Chemotherapy has no role in management of metastatic lymphoepithelioma F Surgery and radiotherapy have constituted the major part of published series in terms of the management of laryngeal and hypopharyngeal LECs. Historically, treatment strategies have remained controversial for LECs.Keeping in view the poor outcome owing to distant metastasis, the role of induction chemotherapy has still remained controversial.Kermani used neoadjuvant chemotherapy with a response rate of 30% at the primary site and 50% at regional nodes. Neo-adjuvant chemotherapy has been recommended in a few studies to reduce the disease volume in a clinically positive lymph node and to decrease the risk of distant failures e) Gene therapy for cancer of the head and neck use viral vectors T- Genetic material is transferred via vectors that may be chemical, physical, or viral. The ideal vector would transfer an exact amount of genetic material into a specific area of each target cell, thereby allowing proper expression of the gene product without causing toxicity. Unfortunately, the ideal vector does not exist. Viruses commonly used in gene therapies include retroviruses, adenoviruses, and herpesviruses. 76. The factors which determine bad prognosis in oral cancer are a) Minor salivary gland tumour T- b) The presence of perineural spread T c) The presence of mandibular invasion T- d) Well differentiated tumour F- e) Coexistent coronary artery disease T- 77. Regarding total laryngectomy a) The hypoglossal nerves are sacrificed F- b) The pre-epiglottic space is entered before tumour resection F- c) The paracarotid tunnel is entered early in surgery T- d) T-shaped repair of the pharynx is associated with pharyngocutaneous fistula formation T- e) The superior horn of the hyoid bone is preserved F- 78. In thyroid surgery a) Recurrent laryngeal nerve is easily injured at the thyrohyoid membrane F- The internal branch of the superior laryngeal pierces through the thyrohyoid membrane along with the superior laryngeal artery (a division of the superior thyroid artery b) Parathyroid gland is preserved in medullary carcinoma T- Evidence of parathyroid abnormalities has not been recognized in eight patients with sporadic medullary carcinoma, making genetic factors dominant in explaining the association of parathyroid hyperplasia and this carcinoma. At operation, parathyroid glands should be evaluated and those that are grossly enlarged removed while preserving parathyroid function. c) Inferior thyroid artery is identified above the internal laryngeal nerve F- It pierces the thyrohyoid membrane above the superior laryngeal artery d) Joll’s triangle is used as a landmark for recurrent laryngeal nerve identification F- Joll’s triangle is concerned with identification and preservation of External branch of superior laryngeal nerve (EBSLN). The superior border is formed by superior attachment of strap muscles, medial border by the midline and lateral border formed by the upper pole of thyroid gland and superior thyroid vessels. EBSLN lies in the floor of the triangle formed by the cricothyroid muscle. The triangle is also named as sternothyroid-laryngeal triangle. e) The non-recurrent laryngeal nerve is found on the left side F- Non-recurrent laryngeal nerve (NRLN) is a rare anomaly which is reported in 0.3%-0.8% of people on the right side and in 0.004% (extremely rare) on the left side. A nonrecurrent laryngeal nerve (NRLN) is a rare anatomical variation in which the nerve enters the larynx directly off the cervical vagus nerve The NRLN was found to originate from the vagus nerve at or above the laryngotracheal junction in 58.3% and below it in 41.7%. A right NRLN was associated with an aberrant subclavian artery in 86.7% of cases. 79. Factors that predispose parotid gland abscess includes a) Duct stenosis T- b) Duct stones T- c) Dehydration T- d) Immunocompromised T- e) Edentulous F- 80. Follicular adenocarcinoma of the thyroid a) Is the second most common thyroid malignancy T- b) Is known as Hurtle cell tumour F hurtle cell tumour -variant of follicular carcinoma should be managed as follicular neoplasm, tend to be more aggressive and uptake of radioiodine is less common Added by ES Hurthle cell carcinoma (HCC) of the thyroid gland is one of the lesser-known thyroid cancer types. It used to be considered a variant of follicular thyroid cancer. It shares certain similarities with follicular cancer of the thyroid, like clinical presentation and pattern of metastatic spread. However, in 2017 World Health Organization classified it as a distinct tumor type owing to significant histopathological and molecular differences with follicular thyroid cancer. Hurthle cell thyroid cancer is now defined as a follicular thyroid cell “derived” cancer and not a variant of follicular cancer itself. c) Metastasized to lungs more common than lymph node T- lymph nodes involvement is less common - 10% 10-15% of patients have distant metastases to bone and lung and initially are evaluated for pulmonary or osteoarticular symptoms (eg, pathologic fracture, spontaneous fracture d) Has psammoma bodies identified an histological study F psammoma bodies for PTC e) Is treated by radioiodine ablation therapy T-Surgical resection with tumor-free margins is the mainstay of therapy for local recurrence along with removal of any remaining thyroid tissue.+/- radioactive iodine therapy 81. Regarding chylous fistula a) It occurs at the same rate on both sides of the neck - F Higher incidence on the left b) Reverse Trendelenburg position will exaggerate the leak - F Trendelenburg position - head down position will exaggerate leak c) Pressure bandage has minimal role in its management - F Pressure dressing applied to prevent accumulation of fluid d) Neck exploration is indicated after 48 hours - F If high output, not reducing in trend, causing biochemical imbalance e) Leaks more than 300 ml/day need to be surgically repaired - F High output > 500ml/day need to consider surgical treatment 82. Regarding radial free forearm flap a) It is a fasciocutaneous flap - T may be osseocutaneous if radial bone is incorporated into the flap b) It is not indicated in burn deformities - T Forearm flap is mostly used in head and neck reconstruction - limited amount of skin available, application limited to small defects - thin and pliable nature is suited in the oral cavity, lip, tongue, buccal mucosa c) The donor site is closed primarily - F closed by skin grafting, or with hatchet flap d) It has a short pedicle - F it has a long pedicle which will readily reach neck recipient vessels e) The patency of radial artery is tested using Allen’s test - F Allen test is an important physical examination performed by clinicians. Because this test evaluates the patency of the ulnar artery and its ability to adequately perfuse the hand in the event of injury or damage to the radial artery. Ask patient to make fist tightly and elevate hand by flexing from elbow. Alternatively, patient can close and open fist for couples of times to increase blood drain from hand. Next, compress ulnar artery and radial artery simultaneously with your thumb or fingers [whichever way is comfortable for you – important thing is the pressure should be enough to block the blood flow]. Patient is then asked to open and relax his/her hand. Hand should appear whitish and blanched. The examiner, then releases pressure from ulnar artery while keeping pressure on radial artery. Then observe how long it takes color of the palm to return normal. If the color returns normal within 5 seconds indicates normal collateral blood circulation of the ulnar artery. 83. The contraindication to radical neck dissection includes a) An untreatable primary disease - T b) Recent Myocardial Infarction - T c) Metastases to liver - T d) Carotid Sheath Involvement - F e) Supraclavicular lymph node involvement - F 84. The corners of consternation (difficult sites) in radical neck dissection are a) The submandibular triangle - T b) The upper end of internal jugular vein - T c) The lower end of omohyoid muscle - F d) The Lower End Of Brachial Plexus - F e) The superior mediastinum - F 85. Regarding the differentiated thyroid cancer a) Medullary type runs in family - T part of MEN syndrome MEN type 2a and 2b b) Papillary type is common in females - T c) Follicular type is easy to diagnose by FNAC - F Scott-Brown: The follicular-patterned lesion is the most commonly encountered type of thyroid FNAC specimen in clinical prac- tice. Distinction between a hyperplastic (adenomatoid) nodule in a multinodular goitre and a follicular-patterned neoplasm may not always be achievable. Reliable discrimination between a benign adenoma and differentiated follicular carcinoma on subjective morphological grounds is now realized to be always difficult, often impossible. Need to look for capsular invasion, tissue sample is needed d) Lymphoma Is One Of The Subtype - F e) Mode of spread in papillary type is hematogenous - F Follicular spread is hematogenous 86. Regarding parotid tumours a) Pleomorphic adenoma has multicentric origin - F Tumor has pseudopods which are outgrowths from the main nodule Multicentric - warthin’s Tumors that can be multicentric include Warthin tumor, oncocytoma, basal cell adenoma and acinic cell carcinoma. The incidence of multiple primary unilateral pleomorphic adenomas is extremely rare in patients with no prior history of trauma or surgery. We report two cases of primary multicentric pleomorphic adenoma and review the literature. b) Warthins is one of the bilateral tumours - T c) Adenocarcinoma has perineural invasion - F d) Open biopsy is an absolute contraindication - F Stell-Maran: e) In retrograde tracing of facial nerve, the cervical branch is a choice - F Buccal branch/ marginal mandibular branch Added by Amy : Postoperative facial nerve weakness can be temporary or permanent. Temporary weakness is much more common and incidence is between 10 and 50 % of parotidectomies. The cause of temporary weakness is neurapraxia, which results from a combination of trauma while dissecting right on the nerve, traction injury to the nerve, heat injury secondary to use of electro-cautery, and prolonged operating time. The incidence of permanent facial nerve injury is generally reported as 0.5 %. The cause of such weakness is due to transection of, or cautery injury to the main trunk. In a large series from France comprising 131 patients of parotid tumor, Gaillard et al. reported that there is a high percentage of facial nerve dysfunction (42.7 % on the first postoperative day) immediately after parotidectomy which gradually improves over time to the tune of 30.7 % at 1 month post op and 0 % at 6 months after the surgery. The marginal mandibular branch was reported as the single most affected nerve branch following parotidectomy (48.2 %). Facial nerve dysfunction after total parotidectomy was found to be significantly higher (P < 0.001) than that in superficial parotidectomy (18.2 % at day 1 and 10.9 % at month 1) In absence of facial nerve monitor, facial nerve is generally located by means of anterograde or retrograde dissection methods. Retrograde dissection is the less commonly used technique with the surgeons preferring this method mostly during revision parotidectomy. Anterograde dissection or proximal surgical identification technique is aimed at identifying the facial nerve at its point of exit from the stylomastoid foramen and is the preferred method of dissecting the facial nerve. Though stylomastoid foramen is anatomically a very constant landmark for facial nerve, but in live surgical situation it is very difficult to find this foramen as it is mainly a palpatory landmark and most importantly because it remains surrounded by thick fascia which is continuous with the periosteum of skull base. Excessive dissection in this area very often leads to permanent paralysis of the nerve. The tympanomastoid suture line is palpable as a hard ridge deep to the cartilaginous portion of the external auditory canal. The facial nerve emerges a few millimeters deep to its outer edge. Tympanomastoid suture can be identified in the cadavers without much difficulty but in live surgery it is basically a palpatory landmark and direct visualization of the suture is practically not possible. Tragal pointer (inferior portion of the cartilaginous canal) is a very popular landmark and facial nerve usually lies around 1 cm deep and inferior to the pointer. The only drawback of the pointer is that it is a cartilaginous structure which is mobile, asymmetrical and has a blunt and irregular tip Mastoid process is also described as one of the landmarks but the process lies deep to the insertion of the sternocleidomastoid muscle and hence it is mainly a palpatory landmark. During parotidectomy lateral retraction of the sternocleidomastoid muscle exposes the posterior belly of digastric muscle. This muscle is very easy to identify by the position (just deep to sternomastoid) and also by the direction of the muscle fibres that run towards the mastoid tip. The facial nerve trunk lies approximately 1 cm above and parallel to the upper border of the digastric muscle near its insertion at the mastoid tip. If the proximal segment of the facial nerve is obscured, retrograde dissection of 1 or more of the peripheral branches may be necessary to identify the main trunk. 1. Ramus frontalis is located by a line from tragus to lateral canthus. 2. Ramus buccalis is located by a line from the tragus towards alae of the nose parallel to the zygoma but 1 cm below. 3. Ramus mandibularis is near the angle of mandible at a point 4-4.5 cm from the attachment of the lobule of pinna. When necessary, the facial nerve can be identified in the mastoid bone by mastoidectomy and followed peripherally. 87. Regarding carcinoma of larynx a) Glottis subgroup is the commonest - T Glottic > Supraglottic > Subglottic b) Level V cervical nodes are first to involve in subglottic carcinoma - F prelaryngeal and paratracheal LN Level V usually not involved Scott-Brown: Lymphatic spread is guided initially by the boundaries between embryological anlagen (arches III–VI) Lymphatic spread of glottic cancer is less common than at other subsites. It has been suggested that the lack of submucosal lymphatics in this area is responsible. However, detailed studies of mucosal cell trafficking have not yet been performed to confirm this. Spread, when it occurs, is to levels II, III, IV and VI. Estimates for the incidence of macroscopic lymph node metastasis by disease stage are: 6 cm in greatest dimension or located below the caudal border of the cricoid cartilage Distant Metastasis (M) M0: No distant metastases M1: Distant metastases present Stage Grouping Stage 0: T1s-N0-M0 Stage I: T1-N0-M0 Stage II: T1-N1-M0 and T2-N0, N1-M0 Stage III: T1, T2, T3-N2-M0 and T3-N0, N1, N2-M0 Stage IVA: T4-any N-M0 and Any T, N3-M0 Stage IVB: Any T-any N, M1 Type 1 is keratinizing squamous cell carcinoma which is associated with EBV infection in around 70% to 80% of the cases. Type 2 is differentiated non-keratinizing carcinoma, and type 3 is undifferentiated nonkeratinizing carcinoma and is the most common form of nasopharyngeal cancer. The latter 2 types are also most responsive to treatment. Almost all cases of type 2 and type 3 are related to EBV and occur in the area where EBV is endemic. Nasopharyngeal cancer with basaloid features is a newer, rarer histologic category, known to behave aggressively. In locally advanced disease (stage II, III, IVA, IVB), bimodality treatment with concurrent cisplatin with radiation therapy is recommended. This should be followed by adjuvant chemotherapy with cisplatin and 5-fluorouracil in patients who can tolerate further treatment. Induction chemotherapy before concurrent chemotherapy and radiation treatment has been studied in a few trials and has shown a good response, although data remains insufficient and this is a category three recommendation. If the residual tumor is seen on follow-up imaging after completion of chemotherapy and radiation treatment, resection of residual tumor and/or neck dissection may be warranted. For metastatic disease (stage IVC), platinum-based combination chemotherapy is recommended. Regimens can include cisplatin/5-FU, cisplatin/paclitaxel, and cisplatin/gemcitabine. Imaging should be repeated within 6 months of completion of treatment to ensure a good response. 94. Regarding benign salivary gland neoplasm a) Pleomorphic adenomas contain both mesenchymal and epithelial cells T b) Genetic alterations associated with the formation of pleomorphic adenoma have been identified T - MFAP4, DST, SLC35, and KCTD15 c) Warthin’s tumour occurs in submandibular gland F - warthin usually lymphoid in intraparotid nodes, other LN dont have d) Hemangiomas are detected within the first year of life T e) Oncocytomas are grossly encapsulated single lesions T Oncocytoma is a rare salivary gland tumor consisting of oncocytes with many hyperplastic mitochondria. It usually occurs in the parotid gland. Clinical diagnosis is often challenging due to the likeness of oncocytoma to other benign and low-grade malignant salivary gland tumors. Also called oxyphilic adenoma · 1 - 2% of salivary gland neoplasms; more frequent than oncocytosis and oncocytic carcinoma. They present as lobulated and mobile mass. Bilateralism is observed in 7% of cases. The ultrasound features of parotid oncocytomas are not specific and include a hypoechoic mass with well-defined margins, like other benign parotid tumors such as pleomorphic adenomas.The reports on MRI of parotid oncocytomas describe these tumors as demonstrating T1 and T2 hyposignal with homogeneous contrast enhancement. The decreased signal intensity on both T1- and T2-weighted images is explained by high cellularity and low free water content of oncocytoma. Diagnosis by fine- needle aspiration cytology (FNAC) may be very difficult. In fact, we observe oncocytic changes in a large variety of neoplastic and non-neoplastic conditions; otherwise focal sampling of the lesion explains cytology misdiagnosis. It has been reported the sensitivity for the detection of oncocytoma by FNAC is 29%. Complete surgical excision is the gold standard of treatment. The choice of total or superficial parotidectomy is predicted preoperatively by clinico-radiological findings, and preoperative tumor extensions. There is no need for adjuvant treatment such as chemotherapy and/or radiotherapy because of benign nature and slow growth rate of the tumor. Nevertheless, we recommend long- term follow-up because some cases of malignant oncocytoma have been reported in the literature. Recurrences are reported in less than 20% of cases, explained by incomplete surgical resection 95. The corner of consternation in radical neck dissection is: a) The submandibular triangle T b) The upper end of the carotid artery F c) The lower end of the internal jugular vein T d) The deep part of the brachial plexus F e) The anterior mediastinum F corner of consternation: upper and lower end of IJV, submandibular triangle, trapezius-clavicular junction 96. Risk factor for pharyngocutaneous fistula is: a) Preoperative anaemia T b) Lymph nodes secondaries T c) Postoperative hematoma T d) An incomplete resection of tumour T e) The presence of tracheostomy tube ?? preop trachy got risk but postop trachy not sure? Pharyngocutaneous fistula (PCF) is the most common complication after total laryngectomy. It considerably increases morbidity, hospitalization time and expense, and delays starting adjuvant radiation therapy 1. Besides prolonging hospital stay, the salivary fistula predisposes to major injury of neck vessels and causes discomfort because of feeding through a nasogastric tube 2. The reported incidence of PCF ranges from 3% to 65% PCF is a complication that appears in the early post-operative period after total laryngectomy – in our patients from the 3rd to the 8th post-operative day As supraglottic tumours require resection of large amounts of pharyngeal mucosa leading to closure under tension, these were considered as a risk factor for fistula formation 5. In another series, only partial pharyngectomy associated with total laryngectomy was statistically significant as a risk factor for PCF. Patients undergoing concurrent neck dissection had a higher incidence of PCF compared with those undergoing standard laryngectomy. We found a higher rate of PCF in the patients who had previously undergone tracheotomy than in those who had not (60% vs. 8% – p = 0.012). This was probably due to higher T stage, fibrosis, and contamination. The histological infiltration of the surgical margins of the tumour (11% negative vs. 38% with positive margins) was correlated with early PCF 97. Regarding tongue carcinoma: a) Subclinical nodal metastases is found in 30% of T1 tumour T - 20 to 50% b) Tumour greater than 1.0cm thick has a 50% risk of nodal metastases T - 3 to 8mm DOI has 40-50% c) The depth of invasion correlated with risk of nodal metastases T d) MRI with gadolinium is useful for assessment of perineural spread T e) Brachytherapy is limited for posterior third of the tongue F - anterior also can 98. Regarding the nasopharyngeal carcinoma: a) The differentiated type is radiosensitive F - differentiated is less radiosensitive b) 75% of patients have palpable cervical lymphadenopathy at diagnosis T - 49-85% c) Cranial nerve VI are the most commonly involved T - based on paper from USM and prof amin T but false if based on CPG lol d) CT scan can accurately localized submucosal disease F - MRI modality of choice e) Platinum based chemotherapy are the most commonly used T - cisplatin and also flurouracil. Platinum based is used to distant mets too 99. Regarding carotid body tumour: a) It is positive for non-specific enolase T b) Splaying of the carotid arteries is a feature T - lyre sign  c) Pre-operative balloon occlusion test is mandatory for type 1 F - only if think need to sacrifice ICA d) Shamblin’s classification aids in planning of surgical intervention T e) Transcervical approach is utilized for its removal T Many immunohistochemical markers are used in diagnosis of neuroendocrine tumors: enzymes (neuron specific enolase, NSE); proteins stored in the secretory granules (chromogranin A and HISL19 protein); resident proteins of the presynaptic vesicles; proteins of the cytoskeleton (neurofilament); catecholamines and indolamines (epinephrine, norepinephrine, dopamine, serotonine); neuropeptides (enkephaline, VIP, corticotropine); molecules with unknown functions (PGP 9.5, myelin associated glycoprotein Leu-7) 100.Regarding pyriform fossa tumour: a)It is common in female age 50-70 years F - more common in males. Postcricoid more common in female b)Dysphagia with referred pain to the ear is characteristic T arnold nerve c) Presentation as neck node with unknown primary is common T neck mets 70% at presentation d) Bilateral neck metastases presents in 10% of cases T e) It tends to present earlier than post-cricoid carcinoma F Darmma added: Hypopharyngeal tumours are detected late as the patients are asymptomatic in the early stages, especially those involving the pyriform sinus. Dysphagia to solid food may be an early presentation in post-cricoid cancers, but is generally seen late in pyriform cancers. Taken from scott brown 101.frozen shoulder syndrome after neck dissection: - SAN injury causing trapezius paresis a) causes winging of the scapula T The trapezius muscle, like the serratus anterior, serves to elevate, retract, and rotate the scapula. The muscle originates from the skull and the spinous processes of the first cervical vertebra through the 12th thoracic vertebra [7, 44]. The primary insertion is along the spine of the scapula [7, 44]. Separated into three components, the superior portion elevates the scapula and rotates the lateral angle upwardly, the middle portion adducts and retracts, and the inferior portion depresses the scapula and rotates the inferior angle laterally [7, 12]. The trapezius is solely innervated by the spinal accessory nerve, or cranial nerve XI, which crosses the posterior cervical triangle superficially before diving vertically along the deep surface of the trapezius [7, 44]. b)associated with pain on shoulder adduction T Abduction? Darmma aded: Signs Limited or loss of sustained abduction of the shoulder is the most common sign. A full passive range of motion may eventually progress to decreased passive range of motion due to adhesive capsulitis (frozen shoulder). The ipsilateral shoulder may droop. Scapular winging or prominence of the medial border of the scapula and protraction may be found. Internal rotation of the humeral head may be found. Atrophy of trapezius muscle may be found. Sternoclavicular joint hypertrophy or subluxation may be caused by abnormal stress on the medial clavicular head after the loss of the trapezius muscle support c)cause subluxation of clavicle F d)is due to traction on spinal accessory nerve T e) is treated by cervical sympathectomy F - physio Darmma added: "Erb's point" is also a term used in head and neck surgery to describe the point on the posterior border of the sternocleidomastoid muscle where the four superficial branches of the cervical plexus—the greater auricular, lesser occipital, transverse cervical, and supraclavicular nerves—emerge from behind the muscle. This point is located approximately at the junction of the upper and middle thirds of this muscle. From here, the accessory nerve courses through the posterior triangle of the neck to enter the anterior border of the trapezius muscle at a point located approximately at the junction of the middle and lower thirds of the anterior border of this muscle. The spinal accessory nerve can often be found 1 cm above Erb's point.[ 102.leukoplakia of oral cavity: a)occurs most commonly at buccal area T Tt has been reported that most frequently it affects the gingivae (20). But other authors also mention the buccal mucosa, gingiva, and alveola ridges (21). Proliferative verrucous leukoplakia has an uncertain etiology. b)is seen mostly in alcoholics T Oral leukoplakia is seen as a predominant white patch in the oral mucosa and is the most common potentially malignant disorder of the oral mucosa. Habits such as tobacco, betel nut chewing and alcohol increases the incidence of oral leukoplakia. Darmma added: Risk factors include all forms of tobacco use forms, including cigar, cigarette, beedi, and pipe. Other synergistic risk factors include alcohol consumption, chronic irritation, fungal infections such as candidiasis, oral galvanism due to restorations, bacterial infections, sexually transmitted lesions like syphilis, combined micronutrient deficiency, viral infections, hormonal disturbances, and ultraviolet exposure c)is treated with laser excision T d)has 20% malignant transformation F I thought leukoplakia 10%, erythroplakia 20 malignant transformation? e)need lifelong follow-up F Darmma added WHO definition of leukoplakia white plaques of debatable risk having excluded other known diseases or disorders that bring no increased risk for malignancy. There are two main types of oral leukoplakia, which are homogenous leukoplakia and non-homogenous leukoplakia. Homogenous leukoplakia comprises of uniformly white plaques that are usually asymptomatic in nature. They have a lower likelihood of turning into malignancy. non-homogenous leukoplakia, is irregular, flat, nodular, or exophytic in nature and resembles mixed red and white non-uniform patches, and has a greater probability of turning into malignancy conventional clinical diagnostic tools for timely detection of leukoplakia include toluidine blue dye, oral brush biopsy kits, and salivary diagnostics and optical imaging system The following factors increase the risk for malignant transformation of leukoplakia: Female gender A long duration of leukoplakia Leukoplakia in non-smokers (idiopathic leukoplakia)  Location on the tongue and/or floor of the mouth Size greater than 20 mm Non-homogeneous type Presence of Candida albicans Presence of epithelial dysplasia 103.during selective supraomohyoid dissection, a)anterior belly of digastric muscle is exposed T b)marginal mandibular nerve is identified inferior to facial artery F superior c)submandibular gland is preserved F removed d)lingual nerve is identified with retraction of stylohyoid muscle F mylohyoid muscle e)hypoglossal nerve is preserved T 104.juvenile recurrent parotitis: a)is associated with sialolith F - duct ectasis However, the main cause postulated to explain pathogenesis of JRP is decreased salivary production with an insufficient salivary outflow through the ductal system which favors ascending salivary gland infections via the oral cavity.3 Partial obstruction due to retention is gradually followed by duct dilatation, which further facilitates infection. b)presents bilaterally F- This pathology is usually unilateral, but can occur bilaterally with symptoms usually more prominent on one side usually unilateral BUT can be bilateral c)is normally resolved after puberty T d)is diagnosed by sialography T e)is treated endoscopically via endoscopic ductal ligation T some journals say can Initially conservative treatment is indicated because the natural history of JRP includes spontaneous resolution in 90% cases. Analgesics, attention to good oral hygiene, massage of the parotid gland, warmth, use of chewing gum and sialogogic agents are helpful. Antibiotic treatment during attack is often proposed to prevent additional damage to the glandular parenchyma while low-dose prophylactic antibiotics have been recommended when an immunoglobulin A deficiency is observed.6 However, recurrent swelling and over a long period can affect patient's social life and school activities. Moreover, few patients can develop sequelae such as recurrent pain, chronic swelling and decrease in glands function. Such patients are candidates for more interventional treatment which can further be substantiated with sialographic evidence of multiple strictures and a need to dilate them along with washing of multiple plaques. Nahlieli et al performed duct probing with lavage, dilation and hydrocortisone injection via sialendoscopy with resolution of symptoms and a very low recurrence rate on follow-up.7 Philippe Katz and colleagues used a less invasive treatment method by performing sialography and installing iodinated oil where recurrences were lesser in such treated cases.3 More aggressive treatment is justified only for those patients with persistent problems and includes parotid duct ligation, parotidectomy or tympanic neurectomy but all have unsatisfactory results.9 another journal : (2) DUCT LIGATION This was popularised by Diamant and Enfors. It has been used successfully by others, though at least one study had described varying results. Geterud et al recommend it as a simple and effective treatment. Juvenile recurrent parotitis (JRP) is defined as recurrent inflammatory parotitis in children of unknown etiology.1 It is a rare condition and characterized by multiple episodes of parotid swelling and/or pain associated with fever or malaise over a period of years. In most cases the symptoms resolve spontaneously after puberty but all children should be screened to exclude Sjogren's syndrome, lymphoma and immunodeficiency including human immunodeficiency virus. Juvenile recurrent parotitis is the second most common cause of parotitis in childhood, only after mumps. It commonly begins between 3 and 6 years of age and is often not diagnosed, goes unnoticed, or is mistaken for the mumps, otitis, or pharyngitis. The disease more frequently affects males but higher distribution in females was found when symptoms appeared later.3 Clinical symptoms of JRP include recurrent parotid inflammation with swelling and pain associated with fever which usually lasts 2–7 days. This pathology is usually unilateral, but can occur bilaterally with symptoms usually more prominent on one side. The natural history of this disease is its recurrence with average number of attacks per year range from 1 to 20.1 In 90% of the patients, the symptoms resolve spontaneously by puberty. In few severe cases there is progression leading to the destruction of the glandular parenchyma with a diminution of its functionality by 50%–80%.4 Although most of the cases are idiopathic, juvenile recurrent parotitis might be the first presenting symptom of an underlying variable immunodeficiency, HIV infection and Sjogren's syndrome. The pathogenesis of JRP remains unclear and the present consensus favors a multifactorial origin. Various factors that have been suggested for the development of JRP include congenital ductal malformations, hereditary genetic factors, viral or bacterial infections, allergy, and local manifestation of an autoimmune disease.1–6 However, the main cause postulated to explain pathogenesis of JRP is decreased salivary production with an insufficient salivary outflow through the ductal system which favors ascending salivary gland infections via the oral cavity. Pathological studies reveal several structural changes in the affected parotid gland, while there is still a debate whether these are the primary abnormalities or the result of multiple episodes of parotitis. Histologically there are intraductal cystic dilatations of peripheral ducts with periductal lymphocytic infiltration, called as sialectasis.1 The ectatic ducts are usually 1–2 mm in diameter and typical have a white appearance of the ductal layer without the healthy blood vessel coverage, when compared with a normal gland.7 This aspect is believed to be characteristic of JRP. Sialectasis was previously diagnosed by sialography, but ultrasound has superseded this technique. Treatment options range from conservative to invasive surgical procedures. Initially conservative treatment is indicated because the natural history of JRP includes spontaneous resolution in 90% cases. Analgesics, attention to good oral hygiene, massage of the parotid gland, warmth, use of chewing gum and sialogogic agents are helpful. Antibiotic treatment during attack is often proposed to prevent additional damage to the glandular parenchyma while low-dose prophylactic antibiotics have been recommended when an immunoglobulin A deficiency is observed.6 However, recurrent swelling and over a long period can affect patient's social life and school activities. Moreover, few patients can develop sequelae such as recurrent pain, chronic swelling and decrease in glands function. Such patients are candidates for more interventional treatment which can further be substantiated with sialographic evidence of multiple strictures and a need to dilate them along with washing of multiple plaques. 105.Medullary thyroid cancer: a)Is the commonest paediatric thyroid cancer F PTC Papillary thyroid carcinoma is the most common type of thyroid cancer in children. It occurs most often in teens. Papillary thyroid carcinoma is often made up of more than one nodule on both sides of the thyroid. b)is related to the multiple endocrine neoplasia type 2A T MEN I (3 Ps) - Pituitary, Parathyroid, Pancreatic MEN IIa (2Ps, 1M) - Pheochromocytoma, Parathyroid, Medullary Thyroid Ca MEN IIb (1P, 2Ms) - Pheochromocytoma, Medullary Thyroid Ca, Marfanoid habitus/mucosal neuroma c)Requires preoperative serum thyroglobulin measurement F Added by ES- thyroglobulin for PTC, MTC is calcitonin Medullary thyroid cancer (MTC) is a tumor arising from the parafollicular cells, or C cells, of the thyroid gland. Medullary thyroid cancer produces calcitonin, and elevated calcitonin level is an essential feature of this tumor. d) Is associated with genitourinary symptoms F e)Is treated with radiotherapy F surgery The primary treatment for medullary thyroid carcinoma (MTC) is extensive and meticulous surgical resection. Indirect or fiberoptic laryngoscopy may be performed prior to surgery to evaluate airway and vocal cord mobility and to provide preoperative documentation of any unrelated abnormalities. Thyroid hormone therapy is not as effective as surgical treatment for MTCs, which are neuroendocrine tumors of thyroid parafollicular cells that do not concentrate iodine. Radiation therapy is also less effective; however, positive surgical margins or mediastinal extension may be an indication for adjuvant radiotherapy, and external beam radiotherapy (EBRT) may provide a palliative benefit in controlling symptoms from bony metastases. 106.Clinical assessment of flap circulation include: a)Its color appearance T b)Drain chart F c)tissue turgor T d) dressing chart F e) dermal bleeding T Darmma added There are many conventional modalities used to monitor blood circulation of a flap, including but not limited to handheld Doppler ultrasonography, flap skin temperature measurement, flap skin color tone monitoring, capillary refilling test, and pinprick examination 107. SAN a) is mostly formed in posterior triangle F b) is contributed by the upper 5 cervical segments T c) runs in jugular foramen T 9,10,11 in jugular foramen d) is identified with the Erb’s point T erb’s point is GAN, 1cm above erb;s is SAN  Added by ES - The main identification point of the nerve is in the posterior triangle, behind the posterior edge of the sternocleidomastoid muscle at Erb's point, which is defined by the exit of the greater auricular nerve from behind the sternocleidomastoid muscle. e) supplies motor input of the SCM T 108 Regarding oncocytoma of parotid gland a) 80% occurs in minor salivary gland F Oncocytoma usually occurs in the elderly and affects the parotid glands in 80%. b) it has eosinophilic granbular cytoplasm T Composed of large oxyphilic cells with bright eosinophilic granular cytoplasm c) it is enhanced with technitium 99 scinbtigraphy T Technetium-99m pertechnetate scintigraphy (salivary scintigraphy) is useful to evaluate parotid gland masses. There are two ways to explain the mechanism of increasing the uptake of technetium-99m pertechnetate by oncocytoma. There is accumulation in cystic spaces due to the absence of intralobular duct. Another theory is that technetiun-99m pertechnatate can concentrate inside the tumor because the cells cannot excrete so much, meaning that the uptake is prolonged. Computed tomography (CT) and magnetic resonance imaging (MRI) are the image modalities of choice, and on CT, the most common finding is a well-defined homogeneous parotid mass. On MRI, these tumors appear hypodense on T1 and T2 sequences. Oncocytes are epithelial cells which appear as cells with abundant granular, eosinophilic cytoplasm, a centrally pyknotic nucleus, and ultrastructurally are crammed with numerous mitochondria of various sizes. The World Health Organization classification of salivary gland neoplasms recognizes three oncocytic entities: oncocytosis, oncocytoma, and oncocytic carcinoma. Oncocytoma is more common than oncocytic carcinomas. d) the recurrence rate is 50% F The recurrence rate has been reported to be 20–30% in incomplete excision or multinodularity cases. e) early neuronal spread is a feature F typically benign neoplasm uncless oncocytic ca 109. Regarding neck dissection for aerodigestive SCC a) cervical mets has worse prognosis than the size of primary lesion T b) level V dissection is indicated in prophylactic setting F c) level 2b dissection is indicated when level 2a is clinically negative F still need to do in case of skip mets d) regional failure is the main cause of treatment failure T e) desmoplastic stromal reactions are associated with reactive lymph nodes F associated with ln mets The results of the study revealed that, in the initial grades, cancer invasion induces a desmoplastic reaction, whereas in the later stages, there is degradation of the stroma, thereby facilitating tumor invasion Conclusion: The study would emphasize the importance of stromal desmoplasia as a prognostic indicator and may help to reflect the biological diversity of oral cancer and predict the clinical outcomes. Darmma added: A desmoplastic reaction is a host response, characterised by a fibrotic connective tissue. It classically occurs due to the presence of malignant cells 110. Regarding thyroid neoplasm: a) The most common mutation is B-RAF.true BRAF mutation is the most common genetic alteration in thyroid cancer, occurring in about 45% of sporadic papillary thyroid cancers (PTCs), particularly in the relatively aggressive subtypes, such as the tall-cell PTC. This mutation is mutually exclusive with other common genetic alterations, supporting its independent oncogenic role, as demonstrated by transgenic mouse studies that showed BRAF mutation- initiated development of PTC and its transition to anaplastic thyroid cance b) RAS mutation testing is recommended in indeterminate categories of cytology. True Only about 4% of thyroid nodules are carcinomas and require surgery. Fine-needle aspiration cytology is the most accurate tool to distinguish benign from malignant thyroid nodules, however it yields an indeterminate result in about 30% of the cases, posing diagnostic and prognostic dilemmas. Testing for genetic mutations, including those of RAS, has been proposed for indeterminate cytology to solve these dilemmas and support the clinician decision making process c) RAS mutation has predilection for follicular neoplasms.True. RAs is for follicular Ca d) RET mutation is associated with anaplastic thyroid carcinoma> False Expressed in MTC The RET proto-oncogene is a 20-exon gene located on chromosome 10q11.2 and encodes a membrane tyrosine kinase receptor. It is expressed in thyroid C cells, but not in normal follicular cells.genetic testing of RET plays a critical role not only in diagnosis but also in assessing the prognosis and course of MTC e) B-RAF mutation are predominant reason for radioiodine avidity. False BRAFV600E mutation significantly reduced radioiodine uptake and decreased the sensitivity to radioactive iodine (RAI) therapy. Type of Thyroid Cancer Mutation Prevalence (%) Papillary BRAF V600E 45 RET/PTC 20 Copy gain PI3KCA 12 RAS 10 PI3KCA 3 Copy gain BRAF 3 PTEN 2 Follicular RAS 45 PAX8/PPARγ 35  Copy gain BRAF 35 Copy gain PI3KCA 12 PTEN true e) Supraglottic carcinoma. False Added by ES from julius notes Risk factors Advanced T stage T4 lesion Advanced N stage Nodal +ve patients. Especially when pre or para tracheal nodes are involved (50-60% involvement) Subglottic involvement 14% chance. Due to tumour having a tendency for circumferential growth with cartilage erosion Pre-operative tracheostomy Due to seedling of tumour into trachea and peristomal soft tissue with tracheostomy Risk drops if laryngectomy done within 48 hours of tracheostomy About 8-25% of cases Failed post-operative radiation (residual tumour) Salvage treatment Pharyngocutaneous fistula post laryngectomy 112. Which are the following statements are true: a) Marrow invasion of the mandible is better identified by CT than MRI. False. MRI is better for marrow invasion b) MRI detects perineural tumour extension better than CT. True c) Ultrasound is the most reliable morphologic imaging technique for thyroid gland in the neck. True d) Ultrasound more reliably detects parathyroid adenoma in the neck than radionuclide scanning. False. Sestamibi is more reliable e)Ultrasound guided fine needle aspiration allows simple diagnostic intervention for evaluation of neck lesions smaller than 1 cm. True 113. A patient is noted to have ptosis of the ipsilateral upper eyelid following a radical neck dissection. This finding is due to inadvertent dissection deep to: a) Internal jugular vein. T b) Common carotid artery. T Horner syndrome is the triad of ptosis, miosis and facial anhidrosis. it developed after radical neck dissection with extensive dissection around the carotid artery for anaplastic thyroid carcinoma c) Brachial plexus. T d) Omohyoid muscle. False e) Phrenic nerve. T ENT Cervical Surgical Procedures Which May Cause Horner’s Syndrome. Thyroid and parathyroid surgery Drainage of a retropharyngeal or parapharyngeal abscess Excision of a cervical schwannoma Sympathectomy Removal of paragangliomas Removal of cervical ganglioneuroma Cervical lymph node dissection 114. The following are contraindications for free tissue transfer in head and neck reconstruction: a) Age greater than 80 years. False. Many studies show age is not a contraaindication b) Age less than 10 years. False Free tissue transfer is highly successful in children. Although data are limited, there appears to be no difference in survival among various free flaps used for head and neck reconstruction in children- from a paper c) Raynaud’s phenomenon. T Not sure as reynauds is recurrent vassospasm of the fingers and toe triggered by cold. dunno is affect head and neck flap. May affect radial forearm flap d) Obesity. false BMI >30 was not independently associated with medical or surgical complications for head and neck free flap recipients- from a paper e) Donor site irradiation. true. poor vascular supply 115. With regards to parapharyngeal tumours: a) Most are neurogenic in origin. False - 0.5% of head and neck tumor - 80% benign, 20% malignant - 50% salivary gland in origin, mainly deep lobe of parotid - Pleomorphic adenoma is the most common tumor; mucoepidermoid most common malignant tumor - 30% neurogenicin origin, most common schwannoma (vagal), second common paraganglioma follow by neurofibroma b) Diagnosis is confirmed by FNAC or open biopsy. False. Diagnosis is via imaging,. Bipsy contraindicated c) Most common salivary gland tumour is mucoepidermoid CA. False. Most common tumor deep lobe pleomorphic adenoma d) Most parapharyngeal neurogenic tumour are vagal schwannomas. True e) Vagal schwannomas produce vocal cord palsy. True Hoarseness is the most common specific symptom due to vocal cord palsy, whereas the pathognomonic sign for vagal schwannoma is a paroxysmal cough during palpation of the mass due to vagal stimulation 116. With regards to acute tonsillitis: a) A preceding viral infection of the upper respiratory infection is a predisposing factor. True could be part of pharyngitis b) In infectious mononucleosis, the absolute lymphocyte count is reduced. False absolute lymphocyte would increase as it is a viral infection c) It may be associated with carbimazole. True The treatment of hyperthyroidism with antithyroid drugs can cause a significant side effect in 0.2 to 0.3% of the cases: agranulocytosis. Infectious complications caused by this condition affect mainly the throat, and tonsillitis is one of its manifestations d) Streptococcus pyogenes is the commonest bacterial cause. True Bacterial infections are typically due to group A beta-hemolytic Streptococcus (GABHS), but Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenza have also been cultured e) Mitral valve stenosis is one of late complications. True Mitral valve stenosis can be caused by a complication of strep throat called rheumatic fever 117. Regarding stomal recurrence: a) The incidence following total laryngectomy ranges from 5-15%. true stomal recurrence is an extremely severe complication after total laryngectomy, and its occurrence rate ranges from 5% to 25% b) The cause include residual disease in paratracheal node. True c) High tracheostomy increase the risk.false d) Sisson type II indicate inferior involvement. False e) External beam radiotherapy is the treatment. False 118. Papillary thyroid carcinoma: a) Is multicentric in majority of cases T b) Demonstrate Orphan Annie nuclei on HPE T c) Has similar biological behaviour and prognosis in all 3 types F d) Is less aggressive in children F MORE AGGRRESSIVE e) Has 60% ten-year survival rate in extrathyroidal lesion T 119. Regarding malignant salivary gland tumour: a) Low grade mucoepidermoid ca is incapable of metastases. True. Rarely mets to neck b) Complete resection of the gland is adequate in treating high grade MEC. False c) Adenoid cystic carcinoma is the commonest malignancy in minor salivary gland. True d) Radiotherapy is not indicated after complete surgical removal in adenoid cystic carcinoma. False e) Perineural invasion is a typical feature in acinic cell carcinoma. False 120. Regarding hypopharyngeal carcinoma: a) Loss of laryngeal crepitus is due to prevertebral involvement. true b) CT is adequate imaging in evaluating the primary tumour. false. mri is the best c) The pyriform sinus is most commonly affected subsite. true The majority (70%) of tumors originate in the pyriform sinus, with around a quarter in the posterior pharyngeal wall and the remaining 5% in the post-cricoid region d) Submucosal spread is uncommon. F e) The first echelon draining the posterior pharyngeal wall is level II. For tumors of the lateral aspect of oropharynx, hypopharynx, and larynx, the first-echelon lymph nodes at highest risk of harboring micrometastasis in the clinically negative neck are the deep jugular lymph nodes at levels II, III, and IV on the ipsilateral side Added ES The retropharyngeal lymph node has been widely studied in nasopharyngeal cancer and was regarded as the first station for nasopharyngeal lymphatic drainage (14, 18). In recent years, its significance in HPC has received increasing attention (6). Our preliminary study (13, 19) reported RPLN metastasis was related to PWC, posterior wall invasion and cervical LN status. And we found that RPLN metastasis is a poor prognosticator for survival. And in this further study, on multivariate analysis, we found not only posterior wall invasion as a risk factor, but also pyriform sinus invasion was a protective factor for LNM in RPLNs. We could conclude this trend: posterior wall invasion tends to drain back directly to the posterior pharyngeal region, while HPCs with piriform sinus invasion are less likely to drain backward. Therefore, for radiologists, if pure piriform sinus is invaded, it can be considered that the retropharyngeal area and contralateral neck could not be included in clinical treatment volume (CTV). While, for patients with tumor invading the posterior wall, not only the retropharyngeal area but also both necks should be included in CTV. Retropharyngeal nodes most often contain metastatic deposits from malignancies of the nasopharynx, pharyngeal wall, and oropharynx including tonsillar fossa and soft palate. 121.Regarding the deep neck space infections: a) The etiologies is different in adults and paediatric T- tonsillitis remains the most common etiology of deep neck space infections in children, whereas odontogenic origin is the most common etiology in adults b) Parapharyngeal space involves the entire length of the neck F- From BOS to greater cornu of the hyoid bone c) Pretracheal space is limited to below the hyoid bone T- Superiorly attach to hyoid, inferiorly -extends to mediastinum and fuses with pericardium d) The peritonsillar space infection is a source T- e) Mediastinitis is a complication T- Mediastinitis, Horner’s , IJV thrombophlebitis, Grisel s syndrome 122. Regarding benign tumours of the oropharynx: a) Squamous cell papilloma is the commonest T- Benign tumors of the oropharyngeal region are rare. Squamous papilloma can be found anywhere in the upper aerodigestive tract, most commonly on the tonsils and on the base of the tongue. They are found to a lesser extent on the hard palate, tip of the tongue, gums, epiglottis, pharynx, and uvula Minor salivary gland tumors,1 rhabdomyomas, leiomyomas, lipomas,2 neurogenic tumors,3 and those of fibrous origin are all very rare lesions that may present in the oropharynx. b) Base of the tongue is the most frequent site T- BOTH BOT and tonsils common sites c) Smooth swelling of the lateral wall requires imaging prior to biopsy T- d) Most tonsillar tumours are benign F benign tumours of tonsils are rare, The most commonly reported benign tumors are papillomas, angioma, fibroma, adenoma, lymphangioma, teratoma, myxoma, lipoma, chondroma, inclusion cyst and teratogenous cyst. e) Salivary gland tumours rarely occur in the soft palate T- The tumors of the soft palate can be classified according to its benign and malignant behavior. The most frequent benign tumors are the papillomas; the mixed tumors (pleomorphic adenoma) and the schwanomas. Among malignant tumors, 95% are squamous cell carcinoma and the 5% left are represented by minor salivary glands tumors, lymphomas, melanomas and other rare entities 123. Regarding tracheo-esophageal puncture: a) Microstoma is a contraindication T b) Bacterial infection is the most common cause of valve failure F candida c) Cricopharyngeal muscle spasm is a contraindication F can do cricopharyngeal myotomy d) Primary puncture is associated with fistula formation in post radiated neck T e) Esophageal inflation test assesses its candidacy T taub test 124. Medullary thyroid carcinoma: a) Arises from follicular cells F- Parafollicular T cells b) Is monitored with serum calcitonin T -valuable tumour marker c) Presented with cervical lymphadenopathy in 90% of cases F- cervical nodal metastasis up to 50% of cases d) Is associated with MEN syndrome T- associated with MEN normally bilateral and multifocal MEN 2 A, 2 B, non MEN-familial, sporadic (unifocal) e) Is treated with adjuvant radiotherapy T- Principle treatment is surgery Darmma added: Surgical resection is the primary treatment for medullary thyroid carcinoma. Medullary thyroid carcinoma does not respond to radioactive iodine (RAI) or conventional chemotherapy. Thyroid- stimulating hormone (TSH) suppression is not required for medullary thyroid cancer as C cells do not have the thyroid-stimulating hormone receptor. As mentioned previously, all patients should be evaluated for hyperparathyroidism and pheochromocytoma (TRO MEN syndrome). If a pheochromocytoma is found, it should be removed prior to thyroidectomy Adjuvant radiotherapy has not been adequately studied but can be considered in extrathyroid extension and extensive nodal disease. Monitoring for Recurrence Two to three months after surgery, serum CEA and calcitonin levels should be assessed. If CEA is within normal limits and calcitonin is not detectable, then the patient is considered cured and has the best prognosis. This group needs to be monitored by annual CEA, calcitonin, and potentially with annual ultrasound (based on symptoms and physical exam). For multiple endocrine neoplasia 2A and 2B, annual exams for hyperparathyroidism and pheochromocytoma are prudent. Detectable calcitonin or elevated CEA two to three months after surgery raises suspicion for residual disease. These patients should have a neck ultrasound and in cases of calcitonin greater than 150 pg/ml, further imaging in the form of CT neck, chest, and abdomen liver protocol evaluating for potential metastatic disease. If the imaging is negative and the patient is asymptomatic, continue close surveillance with the physical exam and calcitonin/CEA measurements. If levels remain stable, no further imaging is needed. There is no indication to treat asymptomatic elevated calcitonin. If the imaging is positive and the patient is symptomatic, surgical resection of residual lesions is indicated. In the case of unresectable disease, radiotherapy can provide potential palliative therapy. Tyrosine Kinase Inhibitors In cases of unresectable and symptomatic disease, tyrosine-kinase inhibitors (TKI) like vandetanib and cabozantinib may be indicated. Vandetanib is an oral receptor kinase inhibitor that inhibits RET, EGFR, and VEGFR. In a phase III study, which included 331 patients with advanced, unresectable, or metastatic medullary thyroid cancer, patients showed improved progression-free survival (PFS) compared to placebo. Cabozantinib is also an oral multikinase inhibitor that inhibits MET, RET, and VEGFR2. A phase III EXAM study showed improvement in PFS in advanced or metastatic medullary thyroid cancer. 125. Regarding superficial parotidectomy: a) Skin infiltration with adrenaline helps facial nerve identification F- -help to raise SMAS flap b) Frey syndrome is avoided with the use of sternomastoid interposition flap T- Darmma added: Frey’s syndrome: more accurately referred to as gustatory sweating. Patients report facial swelling and sweating at the site of the parotidectomy in occurrence with meals. Etiology is believed to be aberrant innervation of the sweat glands with branches emerging from the auriculotemporal nerve after their division during surgery. This provides parasympathetic innervation to the normally sympathetic- innervated sweat glands. Diagnosis is usually based on patient history, however if there is any doubt an iodine-starch test (Minor test) will confirm the diagnosis, where iodine starch placed on the affected area turns blue signaling sweat secretion. The incidence historically has been reported as high as 50 to 100%, though, with modern techniques and the use of SMAS flaps and thicker skin flaps at the time of initial elevation, this is greatly reduced and is now quite rare. Should this develop, surgical treatment options can be disappointing, with the best results obtained using SMAS and superficial temporal artery flaps as a barrier between the surgical site and the skin. Gold standard treatment now is botulinum toxin injection. Relief of symptoms is obtained for 6 to 36 months. It works at the pre-synaptic level of the neuromuscular and neuroglandular junction by blocking the release of acetylcholine c) Anaesthesia of upper third of the pinna is unavoidable F- d) Anterior border of posterior belly of digastric muscle is used to identify the facial nerve T- 1cm above and parallel to the posterior belly of digastric muscle- to locate facial nerve e) Confirmation of salivary fistula is done by painting the starch solution F- Frey s syndrome 126. Regarding sialolithiasis: a) It is most commonly occurring in submandibular salivary glands T-80% submandibular b) 30% of the parotid glands sialolithiasis are radio-opaque T- almost 40% though… 80% nsubmandibular radioopaque 40% parotid radioopaque 20% sublingual radioopaque c) It is bilateral in 70% of cases F -80% submandibular, 80% unilateral, 80% radioopaque d) Calcium phosphate is predom