ENT chapter 7 (head and neck surgery)

71 . What is the appropriate margin of resection for a 2.2-mm-thick melanoma of the scalp?

2 cm

Permanent parotid salivary dysfunction can be expected after what total dose of radiation (mean dose to parotid) ?

25 Gy

Patients with Sjogren disease have which relative risk of developing lymphoma within the involved parotid gland compared to age-matched controls?

40 times

According to 2009 The Bethesda System for Reporting Thyroid Cytopathology, what is the risk of malignancy of follicular lesion of undetermined significance (FLUS) ?

5% to 1 5 %

104. Sentinel lymph node biopsy should be offered when a patient has:

A 3 . 5-mm-thick melanoma of the scalp without ulceration and no clinical evidence of lymph node metastases

In a patient with elevated serum calcium, elevated parathyroid hormone, and elevated urine calcium, the most common diagnosis is:

A single parathyroid adenoma

66. A torus is considered:

A. A developmental over growth

A 70-year-old man presents with a Mohs resection of a lesion of the vertex of the scalp that has produced a 4-cm defect. The pathologic diagnosis is angiosarcoma, and the pathologic margins are questionable. On examination, there are vascular lesions beyond the resection margin stopping at 2 em distal to the margin. Your surgical management of this should be:

Additional resection to at least 4 em beyond the margin regardless of frozen section control

Which of the following salivary cancers is most associated with pain and perineural spread of tumor?

Adenoid cystic cancer

The optimal treatment of advanced-stage nasopharyngeal (NP) carcinoma is:

Adjuvant CRT

Laboratory evaluation of patients with hypopharyngeal and cervical esophageal carcinoma should include:

All of the above

Which of the following represents indications for the use of radiation therapy in patients with tracheal malignancy?

All the above

The development of a cutaneous malignancy is associated with chronic exposure to:

Arsenic

Which laryngeal site is the most at risk of developing radionecrosis?

Arytenoid

106. Rituximab is which kind of drug used in the treatment of certain lymphomas?

B . Monoclonal antibody against CD20

A patient with a T3NO squamous cell carcinoma of the lateral floor of the mouth is to undergo surgical treatment. Which of the following is an appropriate neck dissection in this case?

B . Selective neck dissection of levels I, II, and III (supraomohyoid dissection)

118 . What is the main lower eyelid retractor?

B. Capsulopalpebral fascia

Which of these is the most accurate predictor of disease-related survival for patients with head and neck squamous cell carcinoma?

B. Current use of alcohol and/or tobacco

Which artery is at greatest risk of injury during endoscopic en do nasal anterior cranial base resection?

B. Frontoorbital artery

During a lateral infratemporal approach to the cranial base, exposure of the petrous carotid artery segment requires:

B. Sacrifice of the mandibular nerve and the middle meningeal artery

125. What is the most frequent genetic alteration found in differentiated thyroid cancer?

BRAF

A 3-year-old child presents with hypoglobus and a lesion on examination in the superior orbital rim. A fine-needle aspiration in clinic reveals dendritic histiocytes consistent with Langerhans cell histiocytosis. What is the next step in management?

Bone survey

A patient has a T2 N2A human papillomavirus-positive squamous cancer of the left tonsil. What treatment would you recommend?

C. Chemoradiation therapy (CRT)

A 65-year-old man being treated for T3N2c squamous cell carcinoma of the larynx with adjuvant chemoradiation has significant pain during the fifth week of radiation, requiring hospitalization for fluids and pain control. What should be done with the patient's treatment during the hospitalization?

C. Continue radiation while patient admitted

After an endoscopic endonasal resection of a craniopharyngioma, the patient presented with serum sodium of 1 5 5 mEqfL, high urine output, and a urine-specific gravity of 1.001 . What is the diagnosis and the best treatment option?

C. Diabetes insipidus/DDAVP

110. The commonest presenting symptom of nasopharyngeal (NP) carcinoma is

C. Enlarged cervical lymph node

114. Indications for elective treatment of the neck include all of the following except:

C. Locally advanced basal cell carcinoma (BCC)

87. The most common acute toxicity observed after oral radiation therapy are:

C. Mucositis, dysphagia, and xerostomia

86. Reirradiation as a single treatment modality is a well-defined treatment for recurrent:

C. Nasopharyngeal cancer

A 44-year-old has a pleomorphic adenoma in the tail of the right parotid gland. What is the best intervention?

C. Partial parotidectomy

Which of the following statements best describes the disadvantage of elective neck irradiation (ENI) versus elective neck dissection (END ) ?

C. Prognostic information from histopathology is not known

The optimal treatment of recurrent cervical lymph node metastasis in nasopharyngeal carcinoma is:

C. Radical neck dissection

The optimal treatment for a small recurrent nasopharyngeal (NP) carcinoma in the nasopharynx after radiotherapy is:

C. Radical surgical resection

What is the main advantage of the gastric transposition flap over j ejunal flap in reconstruction of the esophagus?

C. Single anastomosis

113 . What is the gold standard/preferred method for alaryngeal speech?

C. Tracheoesophageal (TE) speech

Merkel cell carcinoma is highly specific for which of the following immunostains?

CK-20

A 45-year-old woman presents with pulsatile tinnitus and occasional instability. An audiogram demonstrates mixed hearing loss, and further radiographic investigations are consistent with a paraganglioma of the temporal bone extending into the otic capsule and replacing the jugular bulb with erosion of the jugulotympanic spine. Your surgical management recommendation should include a discussion of:

Conductive hearing loss, SNHL, temporary facial paralysis, lower cranial nerve paralysis, and risk for stroke

95 . Which of the following statements is correct with regard to chemotherapy?

D . Current standards of care are based on phase III data.

100 . The goal of surgery in secondary hyperparathyroidism is:

D . Reduction of cardiovascular events

A 52-year-old has resection of a buccal cancer with ipsilateral neck dissection. Final pathology reports a 1 9-mm primary with perineural tumor and 2 of 21 nodes involved with microscopic deposits of tumor, and no extracapsular spread. What is the pathologic stage?

D . Tl N2b

The preferred management of adenoid cystic carcinoma limited to the trachea, with no evidence of distant metastatic disease, and involving 3 em of trachea is:

D . Tracheal resection with primary repair

62 . Which of the following patients presents a higher risk for malignant paraganglioma?

D. A patient with a familial history of a pheochromocytoma and a known PGL-4 mutation.

Which of the following is an indication for concomitant chemoradiation after a neck dissection?

D. Extracapsular spread of tumor

Laryngeal preservation in a patient with a T3N2C hypopharyngeal cancer is most likely to be successful with which of these chemotherapy treatments?

D. Induction chemotherapy with docetaxel, cisplatin, and 5 -FU followed by radiotherapy

7 4. Which of the following statements is true for osteoradionecrosis?

D. It requires free tissue transfer when advanced

What is characteristic of paratracheal and paraesophageal lymphatic metastases from a hypopharyngeal carcinoma?

D. Postcricoid tumor involvement

73 . The most important indication for surgery in primary hyperparathyroidism is:

D. Relief of symptoms

109 . The primary treatment for intrabony ameloblastoma requires:

D. Resection with 1 . 0 to 1 . 5 em bony margin

126. What is the only absolute contraindication to primary tracheoesophageal puncture?

D. Separation of trachea and esophageal party wall

Which melanoma subtype demonstrates neurotropism, a low rate of lymph node metastases and is often treated with postoperative radiation therapy?

Desmoplastic

Patients who have undergone chemoradiation are more likely to:

Develop wound problems after salvage surgery

A 40-year-old male smoker presents with hoarseness for 4 months. Office fiberoptic laryngoscopy reveals a superficial hyperkeratotic lesion on the right anterior vocal cord. Cord mobility is normal. What would be the next logical step in management?

Direct laryngoscopy with transoral laser microsurgery (TLM) excisional biopsy

The most common cause of false-positive intraoperative parathyroid hormone (IOPTH) is:

Double adenoma

Which of these is the most common presenting symptom( s) for tracheal adenoid cystic carcinoma?

Dyspnea

9 6 . Free tissue transfer after ablation for recurrent oropharyngeal cancer will result in:

E. A lower requirement for further surgery

Which of these is the most common presenting symptom(s) for tracheal squamous cell carcinoma (SCCA) ?

E. Cough with hemoptysis

For cutaneous squamous cell carcinoma, which of the following locations is considered a high-risk feature for staging purposes?

Ear

Cervical lymph nodes involved by lymphomas have which two appearances on CT scan with contrast?

Enlarged lymph nodes with homogenous appearance and poor contrast enhancement

Which diagnostic procedure is the gold standard in the diagnosis of lymphoma in patients presenting with enlarged cervical lymph node?

Excisional biopsy

Indications for adjuvant chemoradiation include:

Extracapsular spread

What is the most commonly encountered cause for squamous cancer of the tongue base?

Human papillomavirus (HPV) type 16 infection

The following ultrasound features of a thyroid nodule are associated with high probability of malignancy except:

Hyperechogenicity

What is the most common cause for failed tracheoesophageal (TE) voice?

Hypopharyngeal bar

Which of the following is a major constraint to the application of transoral laser microsurgical (TLM) approach for resection of early supraglottic cancer?

Inadequate access

The ophthalmic artery branches off the internal carotid artery medially just after it exits the cavernous sinus and dural rings and runs in which of these directions to the optic nerve inside the optic canal?

Inferolateral

Successful parathyroidectomy is usually best predicted by:

Intra operative parathyroid hormone (PTH ) reduction to normal

Which of the following is true regarding organ preservation therapy for a T4aN 1 squamous cell carcinoma of the larynx?

Is more likely to require salvage laryngectomy

Which of these melanoma subtypes is also referred to as melanoma in situ?

Lentigo maligna

What is not part of MEN Ila syndrome?

Marfanoid habitus

A 45-year-old presents with a left level II neck mass. It measures 28 mm with a cystic center and thick wall. Needle aspiration demonstrates fluid with no cells. What is the likely diagnosis?

Metastasis from the oropharynx

A 47-year-old presents with a firm submucosal mass adjacent to the maxillary first molar. What is the most likely diagnosis?

Minor salivary gland tumor

82. Which is the most common type of basal cell carcinoma (BCC) ?

Nodular

67. Fibrous dysplasia is commonly treated with:

Observation

The utility of sentinel node biopsy is higher in patients with tumors in:

Oral tongue

Which statement is most accurate?

Patients with orbital invasion rapidly develop ocular symptoms, such as proptosis, diplopia, decreased visual acuity, diminished motility, chemosis, lid edema, and epiphora.

117. Which of the following statements about nerve sheath tumors is not accurate?

Peripheral nerve sheath tumors in the nasal cavity and paranasal sinuses lack encapsulation with neoplastic cells undermining adjacent respiratory mucosa.

What is the most reliable method to prevent pharyngeal spasm at the time of primary tracheoesophageal {TE) puncture?

Pharyngeal constrictor myotomy

What structures does the head and neck surgeon have to include when resecting a tumor of the posterior pharyngeal wall that can lead to significant dysphagia?

Pharyngeal plexus

81 . The most commonly used particle for radiation therapy is:

Photon

After completion of chemotherapy and radiotherapy for T2N2B HPV squamous cell carcinoma of the left tonsil, what initial follow-up would you recommend?

Positron emission tomography (PET)/CT 3 months after treatment

A chylous fistula develops following a neck dissection. Upon exploration of the neck to control it, the surgeon would anticipate the thoracic duct to be located:

Posterior to the carotid artery

79. Which statement best describes sinonasal melanomas?

Postoperative radiation therapy may be beneficial for sinonasal mucosal melanoma, although its impact on survival and local control has not been addressed in scientific trials.

What is the most important predictor of better functional outcomes in conservation surgery for supraglottic tumors?

Pulmonary function status

Which of the following treatments is the most appropriate therapy for a patient with a T2N l human papillomavirus-positive oropharyngeal cancer?

Radiation therapy only

64. What is the most common odontogenic cyst?

Radicular

56 . Overexpression of BcL-2 and BeL-X results in which of these situations?

Reduced cell apoptosis (death)

What is the advantage of intensity-modulated radiation therapy (IMRT) over 3D ?

Reduced dose t o the parotid glands and other normal tissues

52. Which statement best describes reconstructive and rehabilitation goals?

Rehabilitation after surgical resection of paranasal sinus tumors may be achieved with a dental prosthesis or reconstructive flaps, such as temporalis muscle flaps with and without the inclusion of cranial bone, pedicled or microvascular free myocutaneous flaps (e.g., pectoralis maj or, latissimus dorsi, trapezius) , and cutaneous flaps (e.g., forehead, scalp, deltopectoral) .

Treatment of a dentigerous cyst requires:

Removal of impacted tooth and enucleation

Which of the following is the first priority in selecting reconstructive options for any size full-thickness lip defect?

Restore competence of the oral sphincter

Neck dissection for a T3NO well-differentiated left lower lip cancer patient for whom XRT is not indicated should involve:

Right level I and left I-III selective neck dissection

Which one of the following statements is correct with regard to the common type, site, and gender distribution of lip tumors?

SCCA typically affects the lower lip and is more common in men.

Which of the following salivary gland tumors is associated with the highest rate of cervical metastases?

Salivary duct cancer

65. What is a potential contraindication for transoral resection of a T2NO tonsil cancer?

Severe trismus

Which of the following arteries can be a source of secondary hemorrhage or major bleeding during transoral laser resection of a supraglottic tumor?

Superior laryngeal artery

During an anterolateral approach with orbitozygomatic osteotomy, all of the following anatomical regions should be addressed for the osteotomies, except:

Superior orbital fissure

Patients who have failed primary chemoradiation of the larynx are best treated by salvage:

Surgery

A 48-year-old patient presents with a 1 .5-cm biopsy-proven, poorly differentiated squamous cell carcinoma of the left ear. Which of the following is the most appropriate stage of the primary tumor (T) ?

T2

Which of the following patients is most likely to benefit from elective neck dissection of levels I to IV?

T2No right lateral tongue

A 5 5 -year-old man presents with a 3-cm right-sided neck mass. Flexible laryngoscopy shows a mass originating on the right aryepiglottic fold extending superiorly onto the epiglottis. Both true vocal cords are mobile. CT scan shows paraglottic space invasion and multiple right-sided lymph nodes none larger than 3 em. What is the TNM stage?

T3 N2bMO

116. Which of the following statements regarding tracheal cancers is true?

The duration of symptoms prior to presentation is longer for adenoid cystic carcinoma than for SCCA.

In the course of a neck dissection, profuse venous bleeding occurs in the area below the posterior belly of the digastrics and anterior to the jugular vein. As multiple clamps are applied to control the bleeding, which of the following nerves is at highest risk of injury?

The hypoglossal

Which of the following is not an indication for radioactive iodine treatment?

Tl NOMO thyroid papillary carcinoma, 3 0-year-old women

120. Which oral site is most commonly afflicted by cancer?

Tongue

90. Which is the most common site involved by lymphoma within Waldeyer ring?

Tonsils

A 15-year-old boy presents with epistaxis and right orbital proptosis with diplopia. Radiographic studies, including a CT scan with and without contrast, and an MRI with contrast are consistent with an advanced juvenile nasopharyngeal angiofibroma extending intracranially on the right with inferior orbital fissure invasion and middle cranial fossa invasion. Your proposed surgical management should include:

Transfacial resection following angiographic embolization with follow-up potential transcranial resection

What is the principal difference in oncological resection technique between transoral laser resection and classic oncological surgery?

Transtumoral cut and multibloc resection

Radiographic imaging for cNO patients results in a significant false-positive rate and the potential for some patients' necks to be overtreated. True or false?

True

Which of these statements best describes lymphoscintigraphy?

Use of radioactive colloid to map the lymphatic pathway

102. Which of these orbital bones contributes to the orbital rims?

Zygomatic

69. The highest incidence of nasopharyngeal (NP) carcinoma is among:

c. Southern Chinese

91 . How many base pairs are in the human diploid genome?

6,000,000,000

93. What is the 5-year overall survival of laryngeal cancer?

63%

A 72-year-old man presents with a 25-mm mass in the tail of the parotid on the left. CT show a second 20-mm mass on the right. What is the most likely diagnosis?

A. Bilateral Warthin tumor

A 28-year-old undergoes partial parotidectomy with facial nerve dissection for a 22-mm tumor. Pathology shows a low-grade mucoepidermoid carcinoma. Margins are negative. The neck is radiologically negative. What therapy do you recommend?

A. No further therapy, observation

A 35-year-old woman presents with a 3-month history of progressing double vision. On examination you note normal acuity, but there is a left cranial nerve 6 palsy. What is the next step?

A. Obtain an MRl and cr

A 70-year-old man presents with a 2-week history of a rapidly enlarging otherwise asymptomatic mass on the right upper lip. Physical examination reveals a 2-cm ulcerated circumscribed lesion with elevated or rolled margins, a keratinized central region, and an indurated base. The initial biopsy report provided by the referring physician was read as "suspicious for squamous cell carcinoma." The next best step in management is:

A. Perform a second incisional biopsy at the margin of the lesion

In patients undergoing chemotherapy and radiation as definitive therapy for hypopharyngeal carcinoma, how should the patient be counseled to minimize significant dysphagia?

A. Referral to speech pathology with administration and performance of therapeutic exercises B. Maintaining a minimal level of PO intake to avoid long-term dysphagia C. Both A and B (this answer)

Eight hours after an uneventful lateral orbitotomy for biopsy of an orbital tumor, your patient notes progressive unrelenting pain and chemosis. What must be considered as a cause for this pain?

A. Retrobulbar hematoma

77. What is the most common complication of tracheoesophageal (TE) voice restoration?

A. TE puncture granulation

Which of the following is a disadvantage of elective neck dissection (END) versus elective neck irradiation (ENI) ?

A. The inability to adequately treat retropharyngeal and para pharyngeal lymph nodes

63. What is the most frequently mutated gene in head and neck cancer?

A. p53

105 . The most accurate radiologic method to stage the NO neck in oral cancer is with:

CT

A 48-year-old has surgery for a T2NO squamous cancer of the lateral tongue. Pathology reveals the margins are negative. There is no perineural tumor and 5 of 24 nodes are involved with extracapsular extension. Best evidence suggests that the patient needs:

Chemoradiation therapy

A 62-year-old man presents with a mass extending from the right true vocal cord superiorly into the ventricle and false vocal cord, which is biopsy-proven squamous cell carcinoma. The true vocal cord is fixed. There is only unilateral disease. What is the best treatment option?

Chemoradiation therapy

Which of the following statements is true?

Chondrosarcomas, arising from cartilaginous structures, are treated with wide-field excision and postoperative radiation if vital structures are involved