Neck Practice Questions

Q: A 45-year-old male presents with bilateral swelling and pain in the floor of his mouth. Which anatomical space is primarily involved in Ludwig's angina?

Submandibular space. ***Submandibular space*** - Ludwig's angina is a rapidly spreading **bilateral cellulitis** that primarily involves the **submandibular spaces bilaterally**. - The submandibular space includes both the **sublingual** (above mylohyoid) and **submylohyoid** (below mylohyoid) compartments. - Characteristic features include **brawny induration** of the neck, **tongue elevation** and posterior displacement, and risk of **airway obstruction**. - The infection typically originates from **lower molar teeth** (2nd and 3rd molars) and spreads through fascial planes. *Sublingual space* - While the **sublingual compartment** is indeed involved as part of the submandibular space, Ludwig's angina is defined by **bilateral submandibular space involvement**, not just sublingual. - The sublingual space alone would not account for the full extent of this condition. *Parotid space* - The **parotid space** contains the parotid gland and is located lateral to the pharynx. - Infections here cause swelling in the **cheek and preauricular area**, not bilateral floor of mouth swelling. - Parotid infections are typically due to **sialadenitis** or abscess formation. *Retropharyngeal space* - The **retropharyngeal space** lies behind the pharynx between prevertebral and buccopharyngeal fascia. - Infections here cause **neck swelling** and **dysphagia** but not the characteristic bilateral floor of mouth involvement. - Risk of **descending mediastinitis** is a serious complication of retropharyngeal space infections.

Q: Following block dissection of the neck, a person is unable to shrug their shoulder and has difficulty turning their head to the opposite side. This is primarily due to damage to which nerve?

Spinal part of the accessory nerve. ***Spinal part of the accessory nerve*** - The **spinal accessory nerve (CN XI)** innervates the **trapezius** and **sternocleidomastoid (SCM) muscles**. - **Trapezius** is responsible for **shoulder elevation** (shrugging) and scapular stabilization. - **SCM** rotates the head to the **opposite side** and assists in neck flexion. - Damage to this nerve during neck dissection (particularly radical neck dissection) commonly occurs and leads to shoulder droop, difficulty shrugging, and impaired head rotation. *Glossopharyngeal nerve* - The **glossopharyngeal nerve (CN IX)** primarily functions in **taste** (posterior third of tongue), **swallowing**, and **salivation**. - It has no direct role in head or shoulder movement. - Damage would typically cause dysphagia, loss of gag reflex, or altered taste sensation. *Vagus nerve* - The **vagus nerve (CN X)** controls **heart rate**, **digestion**, **voice production** (via recurrent laryngeal nerve), and pharyngeal muscles. - It does not innervate muscles responsible for head movement or shoulder elevation. - Damage could lead to hoarseness, dysphagia, or autonomic dysfunction. *Cranial accessory nerve* - The **cranial accessory nerve** (cranial root of CN XI) is functionally part of the **vagus nerve** and contributes to innervation of **laryngeal and pharyngeal muscles**. - It does not innervate the sternocleidomastoid or trapezius muscles. - Its damage would affect swallowing and voice, not head or shoulder movement.

Q: Which artery supplies the suprahyoid muscles in the floor of the mouth?

Lingual artery. ***Lingual artery*** - The **lingual artery**, a branch of the **external carotid artery**, is the **principal arterial supply** to the **floor of the mouth** and is considered the primary vessel for this region. - Its **sublingual branch** directly supplies the **geniohyoid muscle** and contributes to the vascular supply of other suprahyoid structures. - The lingual artery's extensive distribution in the floor of the mouth makes it the most significant vessel for this anatomical region overall. *Facial artery* - The **facial artery** supplies structures of the **face** and gives off the **submental branch** which supplies the **anterior belly of digastric** and **mylohyoid** muscle. - While it contributes to suprahyoid muscle supply, it is not considered the primary vessel for the floor of the mouth region. *Maxillary artery* - The **maxillary artery** supplies deep structures of the **face**, including the **muscles of mastication**, **teeth**, **palate**, and **nasal cavity**. - It does not directly supply the suprahyoid muscles in the floor of the mouth. *Inferior alveolar artery* - The **inferior alveolar artery** is a branch of the **maxillary artery** that gives off the **mylohyoid branch** before entering the mandibular foramen. - The **mylohyoid branch** supplies the **mylohyoid muscle** and **anterior belly of digastric**. - While this artery contributes significantly to individual suprahyoid muscles, the **lingual artery** is considered the principal vessel for the floor of the mouth region as a whole and is the standard answer for this anatomical area.

Q: A neonate while suckling milk can breathe without difficulty due to:

High larynx. ***High larynx*** - A **high larynx** in neonates positions the epiglottis to interdigitate with the soft palate, effectively separating the **airflow channel** from the **foodway** during swallowing. - This anatomical arrangement allows for simultaneous **breathing and suckling** without aspiration, facilitating continuous feeding. *A smaller tongue* - While neonates do have proportionally different oral anatomy, a **smaller tongue** alone does not fully explain the ability to breathe while suckling. - The interaction of multiple structures, including the larynx and soft palate, is key to this function. *A smaller pharynx* - The pharynx in neonates is indeed relatively smaller than in adults, but this reduction in size doesn't directly enable concurrent **breathing and suckling**. - Its primary role in this context is as a pathway for both air and food, which needs to be precisely managed by other structures. *The soft palate* - The **soft palate** plays a crucial role by creating a seal with the epiglottis, but it is the elevated position of the larynx that allows this complete separation. - Without the **high larynx**, the soft palate alone could not adequately prevent aspiration during simultaneous breathing and feeding.

Q: Which of the following statements about the pyriform fossa is incorrect?

The aryepiglottic fold does not form its medial border.. ***The aryepiglottic fold does not form its medial border.*** - This statement is **INCORRECT** because the **medial border** of the **pyriform fossa** is actually formed by the **aryepiglottic fold**. - The aryepiglottic fold extends from the arytenoid cartilage to the epiglottis, separating the piriform fossa from the laryngeal aditus. - This is a key anatomical landmark for understanding the boundaries of the pyriform fossa. *It is the most common site for cancer.* - This statement is also incorrect, but less definitively so from a pure anatomical standpoint. - While the **pyriform fossa** can be a site of **squamous cell carcinoma**, it is **not the most common site** for head and neck cancers. - The **oral cavity** and **oropharynx** are more frequent locations for head and neck cancers owing to a higher incidence of HPV-related and tobacco/alcohol-induced malignancies. *It has a rich nerve supply.* - This statement is **CORRECT**. - The **pyriform fossa** is indeed richly innervated by branches of the **internal laryngeal nerve**, a branch of the superior laryngeal nerve and vagus nerve. - This rich innervation makes it a sensitive area concerning foreign bodies and can elicit strong **gag reflexes** or pain. *It is present on either side of the laryngeal opening.* - This statement is **CORRECT** [1]. - The **pyriform fossae** (or piriform sinuses) are symmetrical depressions located on either side of the **laryngeal inlet** [1]. - These fossae serve as channels for food and liquids to pass into the esophagus, bypassing the airway.

Q: Which structure is most likely injured in a 25-year-old man with a bullet wound in the neck, resulting in a tension pneumothorax and collapse of the right lung?

Cupula. ***Cupula*** - The **cupula** (or cervical pleura) extends into the root of the neck, superior to the first rib, making it vulnerable to neck injuries [1]. - A penetrating injury to this region can directly damage the pleura, leading to **pneumothorax** and subsequent lung collapse [1]. *Costal pleura* - The **costal pleura** lines the inner surface of the thoracic wall and would primarily be affected by injuries directly to the chest wall, not the neck [1]. - Injury to this part of the pleura is less likely to result from a **neck wound** causing a pneumothorax unless the wound extended significantly downwards. *Right mainstem bronchus* - The **right mainstem bronchus** is located deep within the mediastinum and would typically require a much deeper and more centrally located injury to be affected. - While mainstem bronchial injuries can cause **pneumothorax**, a bullet wound in the neck is less likely to reach this structure without causing more extensive mediastinal damage. *Right upper lobe bronchus* - The **right upper lobe bronchus** is also situated within the mediastinum, deep to the pleura and lung parenchyma. - An isolated injury to this bronchus from a neck wound is unlikely; simpler, more superficial structures like the **cupula** are more probable targets.

Q: In an emergency tracheostomy, which structures are least likely to be damaged?

Inferior thyroid artery. ***Inferior thyroid artery*** - The **inferior thyroid artery** is typically located deep and lateral to the trachea, arising from the thyrocervical trunk and approaching the thyroid gland posteriorly [1]. - During emergency tracheostomy, the incision is made in the midline over the 2nd-4th tracheal rings, whereas this artery runs laterally at a lower level (typically around the 6th tracheal ring). - Its **deep and lateral anatomical position** makes it the least vulnerable structure among the options during a standard midline tracheostomy incision [1]. *Isthmus of the thyroid* - The **isthmus of the thyroid gland** crosses the trachea anteriorly, typically overlying the 2nd, 3rd, and 4th tracheal rings. - It lies directly in the path of an emergency tracheostomy incision and is frequently encountered, often requiring division or retraction to access the trachea. - This structure is **highly likely to be damaged** during the procedure. *Thyroid ima artery* - The **thyroid ima artery** is an inconsistent vessel, present in approximately 3-10% of individuals, arising from the brachiocephalic trunk or aortic arch. - When present, it ascends in the **midline** to supply the inferior pole of the thyroid gland, placing it directly in the path of the tracheostomy incision. - This vessel is **highly susceptible to injury** when present, potentially causing significant arterial bleeding. *Inferior thyroid vein* - The **inferior thyroid veins** drain the thyroid gland and form a venous plexus anterior to the trachea, superficial to the thyroid isthmus [1]. - This plexus lies in the **superficial surgical field** and is prone to injury during the midline cervical incision for tracheostomy. - Damage to these veins commonly occurs and can lead to significant venous bleeding [1].

Q: Which of the following is not a branch of the cervical plexus?

Suprascapular nerve. ***Suprascapular nerve*** - The **suprascapular nerve** originates from the **brachial plexus** (specifically the upper trunk), not the cervical plexus. - It primarily innervates the **supraspinatus** and **infraspinatus muscles**. *Lesser occipital nerve* - The **lesser occipital nerve** is a cutaneous branch of the **cervical plexus** (C2) that supplies the skin behind the ear. - It provides sensory innervation to the **scalp posterior to the auricle**. *Greater auricular nerve* - The **greater auricular nerve** is a branch of the **cervical plexus** (C2, C3) and provides sensory innervation to the skin over the parotid gland, mastoid process, and auricle. - It supplies sensation to the **external ear** and the **angle of the mandible**. *Supraclavicular nerve* - The **supraclavicular nerves** (C3, C4) are cutaneous branches of the **cervical plexus** that provide sensory innervation to the skin over the shoulder and upper chest. - They provide sensory innervation to the skin overlying the **clavicle** and the **pectoral region**.

Q: All of the following are branches of the external carotid artery except?

Transverse cervical artery. ***Transverse cervical artery*** - The **transverse cervical artery** is a branch of the **thyrocervical trunk**, which itself originates from the **subclavian artery**, not the external carotid artery. - It supplies muscles in the neck and shoulder region. *Superior thyroid artery* - The **superior thyroid artery** is typically the first branch of the **external carotid artery**. - It supplies the **thyroid gland** and adjacent structures in the neck. *Ascending pharyngeal artery* - The **ascending pharyngeal artery** is the only **medial branch** of the **external carotid artery**. - It supplies the **pharynx**, prevertebral muscles, and middle ear. *Superficial temporal artery* - The **superficial temporal artery** is one of the **two terminal branches** of the **external carotid artery**, forming in the parotid gland. - It supplies the scalp in the temporal region and is palpable anterior to the ear.

Q: Fascia around the nerve bundles of the brachial plexus is derived from which structure?

Deep cervical fascia. ***Deep cervical fascia*** - The **brachial plexus** is enveloped by a fascial sheath known as the **axillary sheath**, which is a direct continuation of the **prevertebral layer of the deep cervical fascia**. - This fascial extension surrounds the neurovascular structures (subclavian/axillary artery and vein, and brachial plexus) as they exit the neck into the axilla. - The prevertebral fascia extends laterally from the cervical vertebrae to form this protective sheath. *Pretracheal fascia* - The **pretracheal fascia** (middle layer of deep cervical fascia) encloses the trachea, esophagus, and thyroid gland. - It lies anterior to the prevertebral fascia and does not extend laterally to surround the brachial plexus. *Prelaryngeal fascia* - This is not a standard anatomical term for a distinct fascial layer. - The larynx is covered by the investing layer and visceral components of the deep cervical fascia. *Carotid sheath* - The **carotid sheath** is a separate fascial compartment formed by contributions from all three layers of deep cervical fascia. - It encloses the common carotid artery, internal jugular vein, and vagus nerve—not the brachial plexus.

Question 1

A 45-year-old male presents with bilateral swelling and pain in the floor of his mouth. Which anatomical space is primarily involved in Ludwig's angina?

Accepted Answer

Submandibular space

Answer

Parotid space

Answer

Sublingual space

Answer

Retropharyngeal space

Question 2

Following block dissection of the neck, a person is unable to shrug their shoulder and has difficulty turning their head to the opposite side. This is primarily due to damage to which nerve?

Accepted Answer

Spinal part of the accessory nerve

Answer

Cranial accessory nerve

Answer

Glossopharyngeal nerve

Answer

Vagus nerve

Question 3

Which artery supplies the suprahyoid muscles in the floor of the mouth?

Accepted Answer

Lingual artery

Answer

Facial artery

Answer

Maxillary artery

Answer

Inferior alveolar artery

Question 4

A neonate while suckling milk can breathe without difficulty due to:

Accepted Answer

High larynx

Answer

A smaller tongue

Answer

A smaller pharynx

Answer

The soft palate

Question 5

Which of the following statements about the pyriform fossa is incorrect?

Accepted Answer

The aryepiglottic fold does not form its medial border.

Answer

It has a rich nerve supply.

Answer

It is present on either side of the laryngeal opening.

Answer

It is the most common site for cancer.

Question 6

Which structure is most likely injured in a 25-year-old man with a bullet wound in the neck, resulting in a tension pneumothorax and collapse of the right lung?

Accepted Answer

Cupula

Answer

Costal pleura

Answer

Right mainstem bronchus

Answer

Right upper lobe bronchus

Question 7

In an emergency tracheostomy, which structures are least likely to be damaged?

Accepted Answer

Inferior thyroid artery

Answer

Isthmus of the thyroid

Answer

Thyroid ima

Answer

Inferior thyroid vein

Question 8

Which of the following is not a branch of the cervical plexus?

Accepted Answer

Suprascapular nerve

Answer

Supraclavicular nerve

Answer

Lesser occipital nerve

Answer

Greater auricular nerve

Question 9

All of the following are branches of the external carotid artery except?

Accepted Answer

Transverse cervical artery

Answer

Superior thyroid artery

Answer

Ascending pharyngeal artery

Answer

Superficial temporal artery

Question 10

Fascia around the nerve bundles of the brachial plexus is derived from which structure?

Accepted Answer

Deep cervical fascia

Answer

Pretracheal fascia

Answer

Prelaryngeal fascia

Answer

Carotid sheath

Neck — MCQs

Neck — MCQs

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