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Head & neck surgery MCQs with answers
10 single-best-answer questions on parotid lumps, neck lumps, tracheostomy, epistaxis and head and neck cancer. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
A 45-year-old woman has a painless, firm, mobile 2-cm lump in front of the ear that has grown slowly over 2 years. Facial nerve function is normal. What is the correct approach?
- Incision and drainage
- Enucleation of the lump through a small incision
- Radiotherapy alone
- Ultrasound with fine-needle aspiration or core biopsy, then superficial (or partial) parotidectomy with preservation of the facial nerve
- Observation for 10 years
Show the answer and explanation
Answer: D. Ultrasound with fine-needle aspiration or core biopsy, then superficial (or partial) parotidectomy with preservation of the facial nerve. Most parotid tumours are benign, and the commonest is a pleomorphic adenoma. Pleomorphic adenomas have finger-like extensions through the capsule, so enucleation leads to recurrence. Excision with a cuff of normal tissue, identifying and preserving the facial nerve, is the standard.
Why not the others? Recurrent pleomorphic adenomas are multifocal and difficult to treat.
References
A 66-year-old has a hard parotid mass that has grown quickly over 3 months, with weakness of the lower face on the same side. What does the facial weakness suggest?
- Mumps
- Sialolithiasis
- A malignant parotid tumour invading the facial nerve; urgent imaging and biopsy, with treatment by a head and neck multidisciplinary team
- Bell’s palsy unrelated to the lump
- A benign pleomorphic adenoma
Show the answer and explanation
Answer: C. A malignant parotid tumour invading the facial nerve; urgent imaging and biopsy, with treatment by a head and neck multidisciplinary team. Facial nerve weakness, rapid growth, pain, skin fixation or cervical lymph nodes suggest malignancy in a parotid lump. Benign tumours almost never cause facial palsy. Treatment usually involves parotidectomy (sometimes sacrificing the involved nerve with reconstruction), neck dissection and radiotherapy.
Why not the others? Never assume coexisting Bell’s palsy in a patient with a parotid mass.
References
A 52-year-old non-smoker has a 3-cm cystic swelling in the upper lateral neck, anterior to the sternocleidomastoid. Which statement is correct?
- In adults over about 40, a cystic lateral neck mass should be treated as a possible cystic lymph node metastasis (often HPV-related oropharyngeal cancer) until proven otherwise
- Antibiotics for 6 weeks
- It is always a branchial cyst and can be excised directly
- Incision and drainage
- Reassure and discharge
Show the answer and explanation
Answer: A. In adults over about 40, a cystic lateral neck mass should be treated as a possible cystic lymph node metastasis (often HPV-related oropharyngeal cancer) until proven otherwise. HPV-related oropharyngeal squamous cell carcinoma often presents in younger, non-smoking adults with cystic neck nodes from a small primary in the tonsil or tongue base. Ultrasound-guided FNA (with p16/HPV testing) and examination of the upper aerodigestive tract are needed before excision.
Why not the others? Excising a metastatic node as a “branchial cyst” compromises treatment.
References
A patient with a tracheostomy on the ward suddenly becomes breathless and hypoxic, with no air movement through the tube. What are the first steps?
- Call for help, apply oxygen to the face and the stoma, remove any inner tube, try passing a suction catheter, deflate the cuff, and remove the tracheostomy tube if the patient is not improving
- Sedate the patient
- Push the tube in further
- Order a chest X-ray first
- Give nebulised salbutamol and wait
Show the answer and explanation
Answer: A. Call for help, apply oxygen to the face and the stoma, remove any inner tube, try passing a suction catheter, deflate the cuff, and remove the tracheostomy tube if the patient is not improving. A blocked or displaced tracheostomy is a life-threatening emergency. The national tracheostomy algorithm prioritises oxygenation via both the upper airway and stoma, checking patency with the inner tube and suction catheter, cuff deflation, and removal of the tube if it is blocked or displaced. Bed-head signs show whether the patient has a patent upper airway.
Why not the others? A laryngectomy patient can be oxygenated only via the stoma.
References
A patient who had a total laryngectomy years ago is unconscious and apnoeic after a collapse. How should he be oxygenated and ventilated?
- Nasal cannula only
- Through the neck stoma (he is a total neck breather), using a paediatric face mask or a laryngeal mask over the stoma, or intubating the stoma
- Bag-and-mask ventilation over the mouth and nose
- Oral intubation
- No ventilation is possible
Show the answer and explanation
Answer: B. Through the neck stoma (he is a total neck breather), using a paediatric face mask or a laryngeal mask over the stoma, or intubating the stoma. After total laryngectomy, the trachea is brought out as a permanent stoma and is no longer connected to the mouth and nose. Oxygen and ventilation must be given via the stoma. Bedside signs and alert cards help staff recognise these patients.
Why not the others? Covering the mouth and nose with a mask achieves nothing.
References
A 25-year-old has a severe sore throat for 5 days, now with trismus, a muffled “hot potato” voice and swelling pushing the uvula to the opposite side. What is the diagnosis and management?
- Viral pharyngitis; reassurance
- Immediate tonsillectomy under local anaesthetic in clinic
- Peritonsillar abscess (quinsy); same-day referral for needle aspiration or incision and drainage, with intravenous antibiotics and analgesia
- Steroid inhaler
- Oral antibiotics and review in 2 weeks
Show the answer and explanation
Answer: C. Peritonsillar abscess (quinsy); same-day referral for needle aspiration or incision and drainage, with intravenous antibiotics and analgesia. Quinsy is a collection of pus next to the tonsil. Drainage relieves the symptoms quickly, along with antibiotics and fluids. Airway compromise, spread into deep neck spaces or sepsis requires urgent senior input.
Why not the others? Antibiotics alone do not treat an established abscess.
References
A 70-year-old on aspirin has a heavy nosebleed. What is the first-line treatment?
- Tilt the head back
- Sit him up, leaning forward, with firm continuous pressure on the soft lower part of the nose for at least 5 minutes (often 10–15), while checking observations
- Stop aspirin permanently
- Pack the nose immediately in every case
- Lie him flat and apply ice to the forehead
Show the answer and explanation
Answer: B. Sit him up, leaning forward, with firm continuous pressure on the soft lower part of the nose for at least 5 minutes (often 10–15), while checking observations. Most nosebleeds come from the anterior septum and stop with sustained pressure. If bleeding continues, cautery of a visible vessel or nasal packing follows. Persistent posterior bleeding may need endoscopic sphenopalatine artery ligation or embolisation.
Why not the others? Tilting the head back makes the patient swallow blood and can cause vomiting.
References
A 58-year-old smoker and drinker has a painless ulcer on the side of the tongue for 5 weeks that has not healed. What should be done?
- Review in 6 months
- Reassure, as mouth ulcers are common
- Antibiotics
- Antifungal gel for 1 month
- Urgent suspected-cancer referral for assessment and biopsy
Show the answer and explanation
Answer: E. Urgent suspected-cancer referral for assessment and biopsy. An unexplained mouth ulcer lasting more than 3 weeks, especially in a smoker or drinker, may be oral squamous cell carcinoma and needs urgent referral. Persistent red or white patches and unexplained neck lumps are other red flags.
Why not the others? Delays in diagnosing oral cancer worsen survival.
References
A 62-year-old smoker has had a hoarse voice for 6 weeks without a cold. What is the correct action?
- Reassure
- Urgent suspected-cancer referral for laryngoscopy
- Antibiotics
- Voice rest for 6 months
- Steroid inhaler
Show the answer and explanation
Answer: B. Urgent suspected-cancer referral for laryngoscopy. Persistent unexplained hoarseness in people aged 45 and over should prompt urgent referral to look for laryngeal cancer. Hoarseness can also come from a recurrent laryngeal nerve palsy due to lung or thyroid cancer, so a chest X-ray is often done too.
Why not the others? Hoarseness in a smoker is not “just a cold” after 3 weeks.
References
Biopsy of a neck lymph node shows metastatic squamous cell carcinoma, but examination and endoscopy of the upper aerodigestive tract find no primary. What is the next step?
- Chemotherapy alone without staging
- Excise the node and discharge
- PET-CT before panendoscopy with targeted biopsies (and often tonsillectomy) to find the primary
- Wait for the primary to appear
- No further tests; radiotherapy to the neck only
Show the answer and explanation
Answer: C. PET-CT before panendoscopy with targeted biopsies (and often tonsillectomy) to find the primary. In metastatic squamous carcinoma of unknown primary, PET-CT before panendoscopy helps find a small primary, often in the tonsil or tongue base, guiding biopsies. Identifying the primary allows more targeted treatment and less radiotherapy-related toxicity.
Why not the others? HPV/p16 testing of the node also points to an oropharyngeal origin.
References