MCQsMCQs for the DOHNSfor the DOHNS

Mr S AhluwaliaMr S Ahluwalia

1. Recurrent Laryngeal Nerve1. Recurrent Laryngeal Nerve

•• A.) Has only motor fibres A.) Has only motor fibres •• B.) Supplies all of the muscles of the B.) Supplies all of the muscles of the

larynxlarynx•• C.) Lies in the C.) Lies in the tracheotracheo oesophageal groove oesophageal groove

on the Lefton the Left•• D.) Hooks under the aortic arch on the D.) Hooks under the aortic arch on the

rightright•• E.) is intimately associated with the E.) is intimately associated with the

superior thyroid arterysuperior thyroid artery

Recurrent Laryngeal Nerve Recurrent Laryngeal Nerve AnswersAnswers

•• A.) FalseA.) False•• B.) FalseB.) False•• C.) TrueC.) True•• D.) FalseD.) False•• E.) FalseE.) False

Recurrent Laryngeal Nerve Recurrent Laryngeal Nerve DiscussionDiscussion

•• Left Left –– under aortic arch (L 6under aortic arch (L 6thth arch artery)arch artery)•• Right Right –– under under subclaviansubclavian artery ( 4artery ( 4thth arch arch

artery)artery)•• Originates from Originates from VagusVagus XX•• Motor to all intrinsic laryngeal muscles Motor to all intrinsic laryngeal muscles

except except cricothyroidcricothyroid (ext (ext larynglaryng n. from sup n. from sup larynglaryng branch of branch of vagusvagus))

•• Sensory to Sensory to subglotticsubglottic mucosa and pharynxmucosa and pharynx

2. Otology2. Otology

•• A.) The A.) The scalascala media and tympani contain media and tympani contain perilymphperilymph whilst the whilst the scalascala vestibulivestibuli contains contains endolymphendolymph

•• B.) B.) ChordaChorda tympani supplies taste to the tympani supplies taste to the posterior 2/3 of the tongueposterior 2/3 of the tongue

•• C.) Tendon of the C.) Tendon of the stapediusstapedius muscle emerges muscle emerges from the base of the pyramidfrom the base of the pyramid

•• D.) Tympanic membrane is approx 1cm in D.) Tympanic membrane is approx 1cm in diameterdiameter

Otology AnswersOtology Answers

•• A.) FalseA.) False•• B.) FalseB.) False•• C.) FalseC.) False•• D.) TrueD.) True

Otology discussionOtology discussion

•• The The scalascala media contains media contains endolymphendolymph (K/(K/nana))•• The The scalscal vestibulivestibuli contains contains perilymphperilymph (k/NA)(k/NA)•• The The scalascala tympani contains tympani contains perilymphperilymph and is and is

continuous with the continuous with the vestibulivestibuli at the apex.at the apex.•• The The chordachorda tympani and facial nerve pass tympani and facial nerve pass

through the middle earthrough the middle ear•• Taste anterior 2/3 tongueTaste anterior 2/3 tongue

3. Thyroid and 3. Thyroid and ParathyroidsParathyroids

•• A.) The thyroid may be supplied by the thyroid A.) The thyroid may be supplied by the thyroid imaima arteryartery

•• B.) The superior B.) The superior parathyroidsparathyroids are derived form are derived form the 3the 3rdrd pouchpouch

•• C.) The thyroid is enclosed by C.) The thyroid is enclosed by platysmaplatysma•• D.) The recurrent laryngeal nerve is intimately D.) The recurrent laryngeal nerve is intimately

related to the inferior thyroid arteryrelated to the inferior thyroid artery•• E.) The thyroid is E.) The thyroid is embryologicallyembryologically related to the related to the

foramen foramen caecumcaecum

Thyroid and Thyroid and ParathyroidsParathyroidsAnswersAnswers

•• A.) TrueA.) True•• B.) FalseB.) False•• C.) FalseC.) False•• D.) TrueD.) True•• E.) TrueE.) True

Thyroid and Thyroid and ParathyroidsParathyroidsDiscussionDiscussion

•• The thyroid is supplied by the superior, The thyroid is supplied by the superior, inferior thyroid and inferior thyroid and thryoidthryoid imaima arteries.arteries.

•• Drained via the sup, middle & Drained via the sup, middle & infinf thyroid thyroid veinsveins

•• Enclosed by Enclosed by pretrachealpretracheal fasciafascia•• Superior Superior parathyroidsparathyroids derived from the 4derived from the 4thth

arch and inferior from the 3arch and inferior from the 3rdrd archarch•• Thyroid descends from the foramen Thyroid descends from the foramen

caecumcaecum

4. Nose and Sinuses4. Nose and Sinuses

•• A.) The nose is supplied exclusively by the A.) The nose is supplied exclusively by the ICAICA

•• B.) The septum is composed of triangular B.) The septum is composed of triangular cartilage and bonecartilage and bone

•• C.) The anterior C.) The anterior ethmoidethmoid artery is a artery is a branch of the ECAbranch of the ECA

•• D.) The nasal valve is situated at the D.) The nasal valve is situated at the middle middle meatusmeatus

Nose and Sinuses AnswersNose and Sinuses Answers

•• A.) FalseA.) False•• B.) FalseB.) False•• C.) FalseC.) False•• D.) FalseD.) False

Nose and Sinuses Nose and Sinuses DiscussionDiscussion

•• Septum Septum –– quadrilateral cartilage, quadrilateral cartilage, vomervomer, , perpendicular plate of the perpendicular plate of the ethmoidethmoid & & maxillary crestmaxillary crest

•• ECA ECA –– Internal maxillary Internal maxillary –– SPA & greater SPA & greater palatine arterypalatine artery

•• ICA ICA –– ophthalmic artery ophthalmic artery –– anterior & anterior & posterior posterior ethmoidalethmoidal arteryartery

•• Nasal valve is ant to the ant Nasal valve is ant to the ant infinf turbinateturbinate

Nasal SeptumNasal Septum

5. Facial Nerve5. Facial Nerve

•• A.) Terminal branches include Temporal A.) Terminal branches include Temporal and and ZygomaticZygomatic

•• B.) Is a purely motor nerveB.) Is a purely motor nerve•• C.) Emerges from the C.) Emerges from the stylomastoidstylomastoid

foramenforamen•• D.) Synapses at the D.) Synapses at the geniculategeniculate ganglionganglion•• E.) Traverses the Internal Acoustic E.) Traverses the Internal Acoustic MeatusMeatus

with the with the VestibulocochlearVestibulocochlear nervenerve

Facial NerveFacial NerveAnswersAnswers

•• A.) TrueA.) True•• B.) FalseB.) False•• C.) TrueC.) True•• D.) TrueD.) True•• E.) TrueE.) True

Facial nerve Facial nerve DiscussionDiscussion

•• Motor and sensoryMotor and sensory•• InfratemporalInfratemporal & & ExtratemporalExtratemporal portionsportions•• StylomastoidStylomastoid foramen and divides into T, foramen and divides into T,

Z, B, M, C nerves within parotid glandZ, B, M, C nerves within parotid gland•• Facial expression, Facial expression, lacrimationlacrimation, salivation, salivation•• Taste sensation anterior 2/3 of tongueTaste sensation anterior 2/3 of tongue

6. Muscles of the Larynx6. Muscles of the Larynx

•• A.) Cricothyroid tenses the vocal foldsA.) Cricothyroid tenses the vocal folds•• B.) Lateral B.) Lateral cricoarytenoidcricoarytenoid abducts the vocal foldsabducts the vocal folds•• C.) Posterior C.) Posterior cricoarytenoidcricoarytenoid abducts the vocal abducts the vocal

foldsfolds•• D.) D.) ThyroarytenoidThyroarytenoid is supplied by the recurrent is supplied by the recurrent

laryngeal nervelaryngeal nerve•• E.) Cricothyroid is supplied by the external E.) Cricothyroid is supplied by the external

laryngeal nervelaryngeal nerve

Muscles of Larynx Muscles of Larynx AnswersAnswers

•• A.) TrueA.) True•• B.) FalseB.) False•• C.) TrueC.) True•• D.) TrueD.) True•• E.) TrueE.) True

Muscles of Larynx Muscles of Larynx DiscussionDiscussion

•• Tensor Tensor –– Cricothyroid Cricothyroid –– External Laryngeal External Laryngeal NerveNerve

•• RelaxorRelaxor –– ThyroarytenoidThyroarytenoid –– RLNRLN•• Adductor Adductor –– Lateral Lateral CricoarytenoidCricoarytenoid –– RLNRLN

-- Transverse Transverse ArytenoidArytenoid -- RLNRLN•• Abductor Abductor –– Posterior Posterior CricoarytenoidCricoarytenoid -- RLNRLN

7. The tonsil7. The tonsil

•• A.) A.) PalatoglossusPalatoglossus lies anterior to the tonsillies anterior to the tonsil•• B.) The tonsil is supplied by the tonsillar B.) The tonsil is supplied by the tonsillar

artery, a branch of the pharyngeal arteryartery, a branch of the pharyngeal artery•• C.) The ECA lies 2.5cm behind and lateral C.) The ECA lies 2.5cm behind and lateral

to the tonsilto the tonsil•• D.) Lymph drains to the upper deep D.) Lymph drains to the upper deep

cervical & cervical & jugulodigastricjugulodigastric lymph nodeslymph nodes

Tonsil AnswersTonsil Answers

•• A.) TrueA.) True•• B.) FalseB.) False•• C.) FalseC.) False•• D.) TrueD.) True

Tonsil DiscussionTonsil Discussion

•• The tonsil lies between the The tonsil lies between the palatoglossuspalatoglossusand and palatopharyngeuspalatopharyngeus, superiorly the , superiorly the palate and inferiorly the tongue.palate and inferiorly the tongue.

•• Supplied by the tonsillar artery via the Supplied by the tonsillar artery via the facial artery.facial artery.

•• The ICA lies 2.5cm behind & lateral to the The ICA lies 2.5cm behind & lateral to the tonsiltonsil

Insulin Diabetic Patient undergoing Insulin Diabetic Patient undergoing total thyroidectomy, shouldtotal thyroidectomy, should

a.a. Be admitted 1 hour before surgeryBe admitted 1 hour before surgeryFalseFalse

b.b. Receive preReceive pre--operative insulinoperative insulinFalseFalse

c.c. Receive intravenous normal saline preoperativelyReceive intravenous normal saline preoperativelyFalseFalse

d.d. Receive a glucose, insulin and potassium infusion Receive a glucose, insulin and potassium infusion preoperativelypreoperativelyTrueTrue

e.e. Should receive intravenous insulin Should receive intravenous insulin intraoperativelyintraoperativelyFalseFalse

IDDM surgical patientsIDDM surgical patients

•• All patients must be admitted before any period of All patients must be admitted before any period of starvationstarvation

•• Normal insulin dose regimes usually include Normal insulin dose regimes usually include intermediate/long acting insulin, therefore stop all intermediate/long acting insulin, therefore stop all normal dosesnormal doses

•• Maintain hourly blood glucose readings between 6Maintain hourly blood glucose readings between 6--12 12 mmolmmol/L using a dextrose, insulin and potassium sliding /L using a dextrose, insulin and potassium sliding scale infusionscale infusion

•• Run patientRun patient’’s s ‘‘hyperglycaemichyperglycaemic’’ during surgeryduring surgery•• Keep on sliding scale until back to normal diet, and then Keep on sliding scale until back to normal diet, and then

watch BMs closely whilst on normal watch BMs closely whilst on normal s/cs/c insulin regimeinsulin regime

Total serum Total serum thyroxinethyroxine is reduced byis reduced by

a.a. Oral contraceptive pillsOral contraceptive pillsFalseFalse

b.b. PregnancyPregnancyFalseFalse

c.c. NephroticNephrotic SyndromeSyndromeTrueTrue

d.d. PropanololPropanololFalseFalse

Total serum Total serum thyroxinethyroxine

•• ThyroxineThyroxine (T4) is present in serum as free T4 and bound (T4) is present in serum as free T4 and bound T4. The bound form predominates and is bound to T4. The bound form predominates and is bound to thyroglobulinthyroglobulin (TBG), (TBG), prealbuminprealbumin and albuminand albumin

•• This bound form of T4 serves as a reservoir, hence This bound form of T4 serves as a reservoir, hence buffers against wild fluctuations of free/active T4buffers against wild fluctuations of free/active T4

•• In pregnancy, TBG rises, reducing free T4 which In pregnancy, TBG rises, reducing free T4 which stimulates TSH production, and therefore T4 production. stimulates TSH production, and therefore T4 production. Total T4 therefore rises, although free T4 does notTotal T4 therefore rises, although free T4 does not

•• In In NephroticNephrotic syndrome, TBG and albumin is lost. Free T4 syndrome, TBG and albumin is lost. Free T4 consequently rises, inhibiting TSH production and T4 consequently rises, inhibiting TSH production and T4 synthesis. Total T4 therefore fallssynthesis. Total T4 therefore falls

The following are The following are absorbableabsorbable suturessutures

a.a. Cat gutCat gutTrueTrue

b.b. SilkSilkFalseFalse

c.c. Polyamide (Nylon)Polyamide (Nylon)FalseFalse

d.d. PolyglactinPolyglactin ((VicrylVicryl))TrueTrue

e.e. PolyglyconatePolyglyconate ((MaxonMaxon))FalseFalse

SuturesSutures

AbsorbableAbsorbable NonNon--absorbableabsorbable

Cat gutCat gutPolydioxanonePolydioxanone (PDS)(PDS)PolyglactinPolyglactin ((VicrylVicryl))VicrylVicryl RapideRapide, , MonocrylMonocryl etcetc

Polyamide (Nylon)Polyamide (Nylon)Polypropylene (Polypropylene (ProleneProlene))PolytetrafluoroethylenePolytetrafluoroethylene(PTFE or (PTFE or GoretexGoretex))SilkSilk

Surgery on the submandibular glandSurgery on the submandibular gland

a.a. An incision on the lower border of the mandible is safeAn incision on the lower border of the mandible is safeFalseFalse

b.b. The submandibular gland is seen to wrap around the The submandibular gland is seen to wrap around the posterior border of posterior border of mylohyoidmylohyoidTrueTrue

c.c. The facial artery and vein are divided as they course The facial artery and vein are divided as they course through the deep part of the glandthrough the deep part of the glandFalseFalse

d.d. The hypoglossal nerve is seen to loop under the The hypoglossal nerve is seen to loop under the submandibular ductsubmandibular ductFalseFalse

e.e. Damage to the lingual nerve will cause loss of Damage to the lingual nerve will cause loss of sensation to the posterior third of the tonguesensation to the posterior third of the tongueFalseFalse

Submandibular gland surgerySubmandibular gland surgery

•• Incision is usually two finger breaths below mandible to Incision is usually two finger breaths below mandible to avoid marginal avoid marginal mandibularmandibular nervenerve

•• Gland has deep and superficial parts that wrap around Gland has deep and superficial parts that wrap around posterior border of posterior border of mylohyoidmylohyoid

•• Facial vessels are divided and Facial vessels are divided and ligatedligated superficial to the superficial to the gland. Artery hooks over the top of gland, and may be gland. Artery hooks over the top of gland, and may be encountered several times!encountered several times!

•• Lingual nerve and not hypoglossal Lingual nerve and not hypoglossal ‘‘double crossesdouble crosses’’ the the duct. Passing under the duct, from lateral to medial, duct. Passing under the duct, from lateral to medial, then running forwards on then running forwards on hyoglossushyoglossus at a level above at a level above the ductthe duct

•• Lingual nerve supplies the anterior two thirds of the Lingual nerve supplies the anterior two thirds of the tonguetongue

A 11 month old child presenting with a A 11 month old child presenting with a midline cystic swelling just below the midline cystic swelling just below the

midlinemidlinea.a. Ultrasound is helpful in the diagnosisUltrasound is helpful in the diagnosis

TrueTrueb.b. Technetium scanning aids diagnosisTechnetium scanning aids diagnosis

TrueTruec.c. Typically has an associated lingual thyroidTypically has an associated lingual thyroid

FalseFalsed.d. Often resolves spontaneouslyOften resolves spontaneously

FalseFalsee.e. Often recurs if excision does not remove the body of Often recurs if excision does not remove the body of

the hyoidthe hyoidTrueTrue

OtosclerosisOtosclerosis

a.a. Patients often require surgery in both earsPatients often require surgery in both earsTrueTrue

b.b. OtoscopyOtoscopy is normalis normalTrueTrue

c.c. May be associated with a white forelock and May be associated with a white forelock and heterochromiaheterochromiaFalseFalse

d.d. Causes conductive hearing lossCauses conductive hearing lossTrueTrue

e.e. May be associated with blue scleraMay be associated with blue scleraTrueTrue

OtosclerosisOtosclerosis

•• Only 15% of Only 15% of otosclerosisotosclerosis is truly unilateralis truly unilateral•• The The ‘‘flamingo flushflamingo flush’’ or or SchwartzeSchwartze sign is very uncommonsign is very uncommon•• Unilateral SNHL, white forelock, eye lid deformity with Unilateral SNHL, white forelock, eye lid deformity with

heterochromiaheterochromia describes describes WaardenburgWaardenburg’’ss syndrome (AD syndrome (AD syndrome)syndrome)

•• Conductive loss occurs. Conductive loss occurs. CarhartCarhart’’ss notch is a rise in BC notch is a rise in BC thresholds at 2kHz due to stapes inertiathresholds at 2kHz due to stapes inertia

•• There is an association with There is an association with OsteogenesisOsteogenesis ImperfectaImperfecta

Juvenile Juvenile angiofibromaangiofibroma

a.a. Patients have often had repeated episodes of epistaxisPatients have often had repeated episodes of epistaxisTrueTrue

b.b. It is a tumour of young boys with a mean age of 14 at It is a tumour of young boys with a mean age of 14 at presentationpresentationTrueTrue

c.c. Bone erosion of the greater wing of the sphenoid does Bone erosion of the greater wing of the sphenoid does not occurnot occurFalseFalse

d.d. External beam radiotherapy is firstExternal beam radiotherapy is first--line treatmentline treatmentFalseFalse

Juvenile Juvenile angiofibromaangiofibroma

•• Tumour of young boys who suffer severe bouts of Tumour of young boys who suffer severe bouts of epistaxis, epistaxis, hyponasalhyponasal speech and otalgiaspeech and otalgia

•• Starts in the sphenopalatine foramen, invades the Starts in the sphenopalatine foramen, invades the pterygopalatinepterygopalatine fossa, and then the fossa, and then the infratemporalinfratemporal fossa fossa to eventually erode the anterior face of the greater wing to eventually erode the anterior face of the greater wing of the sphenoidof the sphenoid

•• Surgery with preSurgery with pre--operative operative embolisationembolisation gives best gives best resultsresults

•• Never biopsy the tumour!Never biopsy the tumour!

TracheostomyTracheostomya.a. Fenestration is made through the first tracheal ringFenestration is made through the first tracheal ring

FalseFalseb.b. Can lead to tracheal Can lead to tracheal stenosisstenosis

TrueTruec.c. Recurrent laryngeal nerves must be identified and Recurrent laryngeal nerves must be identified and

displaceddisplacedFalseFalse

d.d. Increases anatomical dead spaceIncreases anatomical dead spaceFalseFalse

e.e. Improves the efficiency of coughing and therefore Improves the efficiency of coughing and therefore improves bronchial toiletimproves bronchial toiletFalseFalse

TracheostomyTracheostomy

•• Fenestration is usually made between the 2Fenestration is usually made between the 2ndnd and 3and 3rdrd

ringsrings•• Large circumferential fenestrations may lead to Large circumferential fenestrations may lead to stenosisstenosis

following following decannulationdecannulation•• Recurrent laryngeal nerves are not usually identifiedRecurrent laryngeal nerves are not usually identified•• Anatomical dead space is reduced. Air no longer passes Anatomical dead space is reduced. Air no longer passes

through the nose, through the nose, nasonaso and oropharynx and and oropharynx and supraglottissupraglottis•• Reduces the efficiency of coughing but allows bronchial Reduces the efficiency of coughing but allows bronchial

toilet in those who have lost ability to coughtoilet in those who have lost ability to cough

Vocal cord nodulesVocal cord nodulesa.a. May become malignantMay become malignant

FalseFalseb.b. Respond favourably to speech therapy in most patientsRespond favourably to speech therapy in most patients

TrueTruec.c. Are always bilateralAre always bilateral

FalseFalsed.d. Are related to the consumption of dark spiritsAre related to the consumption of dark spirits

FalseFalsee.e. Should be removed by microsurgical techniques to Should be removed by microsurgical techniques to

exclude an early squamous cell carcinomaexclude an early squamous cell carcinomaFalseFalse

Glossopharyngeal nerveGlossopharyngeal nervea.a. Is the nerve of the 2Is the nerve of the 2ndnd branchial archbranchial arch

FalseFalseb.b. Is motor to the intrinsic lingual musclesIs motor to the intrinsic lingual muscles

FalseFalsec.c. Is motor to some extrinsic lingual musclesIs motor to some extrinsic lingual muscles

FalseFalsed.d. Supplies sensation to the middle ear mucous Supplies sensation to the middle ear mucous

membranemembraneTrueTrue

e.e. Is deep to the tonsillar fossaIs deep to the tonsillar fossaTrueTrue

Glossopharyngeal nerveGlossopharyngeal nerve

•• Is the nerve of the 3Is the nerve of the 3rdrd branchial archbranchial arch•• Glossopharyngeal nerve is motor to only one muscle, the Glossopharyngeal nerve is motor to only one muscle, the

stylopharyngeusstylopharyngeus•• Sensory Sensory innervationinnervation includes carotid body, taste to includes carotid body, taste to

posterior third of tongue, posterior third of tongue, secretomotorsecretomotor fibres to the fibres to the parotid glandparotid gland

•• May be section through a tonsillectomy approach for May be section through a tonsillectomy approach for glossopharyngeal neuralgiaglossopharyngeal neuralgia

The following structures are removed in the The following structures are removed in the operation of a radical neck dissectionoperation of a radical neck dissection

a.a. TrapeziusTrapeziusFalseFalse

b.b. External carotid arteryExternal carotid arteryFalseFalse

c.c. SternothyroidSternothyroid musclemuscleFalseFalse

d.d. Submandibular glandSubmandibular glandTrueTrue

e.e. OmoOmo--hyoid musclehyoid muscleTrueTrue

Other structures include Other structures include accesoryaccesory nerve, nerve, sternocleidomastoidsternocleidomastoid muscle and IJVmuscle and IJV

Match the following patients with the most Match the following patients with the most appropriate form of imagingappropriate form of imaging

•• CTCT

•• MRIMRI

•• Soft tissue neck XSoft tissue neck X--rayray

•• Ultrasound with fine needle Ultrasound with fine needle aspiration cytologyaspiration cytology

•• A dominant nodule in the A dominant nodule in the left thyroid lobeleft thyroid lobe

•• Sudden Sudden sensorineuralsensorineuralhearing losshearing loss

•• Suspected fishbone in the Suspected fishbone in the hypopharynxhypopharynx

•• Patient with nasal polyps Patient with nasal polyps not resolving with medical not resolving with medical treatment treatment

The following are 10 year survival rates for The following are 10 year survival rates for localised thyroid cancer following treatmentlocalised thyroid cancer following treatment

•• Less than 1%Less than 1%

•• Less than 10%Less than 10%

•• Between 50Between 50--80%80%

•• Better than 80%Better than 80%

•• Sporadic (nonSporadic (non--hereditary) hereditary) MedullaryMedullary Thyroid CarcinomaThyroid Carcinoma

•• AnaplasticAnaplastic thyroid carcinomathyroid carcinoma

•• Papillary thyroid carcinomaPapillary thyroid carcinoma

•• Follicular thyroid carcinomaFollicular thyroid carcinoma

Matching the following cases with the Matching the following cases with the named syndromesnamed syndromes

•• KartagenerKartagener’’ss

•• YoungYoung’’ss

•• Cystic FibrosisCystic Fibrosis

•• OslerOsler--WeberWeber--RenduRendusyndromesyndrome

•• Patient has obstructive Patient has obstructive azoospermiaazoospermia, , sinusitis and sinusitis and bronchiectasisbronchiectasis. . CiliaryCiliarymotility is normalmotility is normal

•• Patient with Patient with situssitus inversusinversus, sinusitis , sinusitis and and bronchiectasisbronchiectasis. Cilia are found to . Cilia are found to be immotile on electron microscopybe immotile on electron microscopy

•• Patient has chronic Patient has chronic bronchopulmonarybronchopulmonaryinfection, infection, malabsorptionmalabsorption and high and high sodium content in sweatsodium content in sweat

•• Patient has recurrent nose bleedsPatient has recurrent nose bleeds