Bailey Reading Ch.

7
21-50
Arpan
 21 . Which of the following represents
indications for the use of radiation therapy in
 patients with tracheal malignancy?
 A. Positive surgical margins
 B. Resected tumors that are high grade
 C. Resected tumors that demonstrate
perineural invasion
 D. Regional nodal metastasis
 E. All the above
 2 1 . Answer: E.
 Indications for radiation therapy i n patients with
tracheal malignancies include those who are not
considered to be good surgical candidates (primary
radiation) and in those requiring adjuvant radiation
therapy for positive surgical margins, high-grade
histopathology, lymphatic involvement, perineural
invasion, and invasion that extends outside of the
airway. Hypofractionated tomotherapy allows for
three-dimensional coverage of at-risk areas following
surgical resection and may limit dose to the
esophagus and surrounding trachea, lung, and
mediastinum, and therefore, lessen the side effects of
radiation. PAG E 1 995
 22. Patients with Sjogren disease have
which relative risk of developing
lymphoma within
 the involved parotid gland compared to
age-matched controls?
 A. 10 times
 B. 20 times
 C. 30 times
 D. 40 times
 22. Answer: D. Patients with Sj ogren
disease have more than 40 times greater
relative risk of developing non-Hodgkin
lymphoma (NHL) within the affected
parotid glands compared to normal age-
matched cohorts. These patients also
have an overall 4% prevalence of NHL.
PAG E 2038
 23 . Neck dissection for a T3NO well-
differentiated left lower lip cancer patient for
whom XRT is not indicated should involve:
 A. Right level I and left I-III selective neck
dissection
 B . Left parotid and left I-III selective neck
dissection
 C. Left modified radical (I-V) neck dissection
 D . Left I-III selective neck dissection
 E. No neck dissection as the risk of cervical
metastasis is low
 23 . Answer: A.
 In patients without clinical evidence of nodal
disease, elective neck dissection is indicated
for advanced-stage lesions. Because the
lower lip lymphatics drain to both ipsilateral
and contralateral submental and
submandibular lymph nodes, these nodes
must be addressed at surgery and
comprehensive selective neck dissection of
ipsilateral levels I- III is indicated. PAG ES 1
793-1 794
 24. What is the most important predictor
of better functional outcomes in
conservation surgery for supraglottic
tumors?
 A. Pulmonary function status
 B. Age
 C. Type of surgical approach
 D. Extent of resection
 24. Answer: A. It is clear that the extent
of surgery will impact functional recovery
after larynx sparing surgical procedures .
At the heart of it all is the fact that all
horizontal partial laryngectomy
procedures, including endoscopic
resections, cause aspiration and patients
without the functional reserve to survive
will suffer the consequences . PAG E 1
949
 25. Which of the following is a major
constraint to the application of transoral
laser microsurgical (TLM) approach for
resection of early supraglottic cancer?
 A. Advanced age
 B. Inadequate access
 C. Recurrent tumor
 D. Questionable preepiglottic space
involvement
 2 5 . Answer: B. The maj or contraindication
to TLM for early supraglottic cancers is
inadequate
 transoral access to the entire tumor.
Adequate laryngeal exposure is the basic
technical
 requirement for TLM. Age, recurrent tumor,
and preepiglottic space involvement are not
 contraindications to TLM. PAG ES 1 943, 1 95
1
 26. Indications for adjuvant
chemoradiation include:
 A. Extracapsular spread
 B. Three or more lymph nodes involved by
tumor
 C. Stage N disease
 D. Perineural invasion
 26. Answer: A. Clinical trial data have
shown that only patients with high-risk
features o f
 microscopically involved margins or
extracapsular spread in lymph nodes in
pathologic
 specimens from surgery benefited from
the addition of platinum-based
chemotherapy to
 postoperative radiation. PAG E 1 701
 2 7. Permanent parotid salivary
dysfunction can be expected after what
total dose of radiation (mean dose to
parotid) ?
 A. 1 0 Gy
 B . 25 Gy
 C. 5 5 Gy
 D . 70 Gy
 27. Answer: B . Different tissues have
different radiation toxicity levels. The lens
of the eye is
 affected by 10 Gy and the optic chiasm at
5 5 Gy. PAG E 1 685
 28. 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:
 A. Anterior to the carotid and posterior to the
jugular vein
 B. Anterior to the carotid and the jugular vein
 C. Posterior to the thyrocervical trunk
 D. Posterior to the carotid artery
 E. In between the subclavian artery and vein
 28. Answer: D . The thoracic duct is
located at the base of the neck, medial
and deep to the
 carotid artery and vagus nerve. It may
have multiple branching tributaries
 29. Which of these statements best describes
lymphoscintigraphy?
 A. Radiation treatment of the lymph node
basin
 B . Use of radioactive colloid to map the
lymphatic pathway
 C. A type of positron emission tomography
scanning to visualize the lymph nodes
 D. Use of external beam radiation to identify
sentinel lymph nodes
 29. Answer: B. Localization and mapping of
sentinel lymph nodes typically involves
preoperative
 and intraoperative use of technetium- 9 9 m-
labeled sulfur colloid, which is inj ected
 intradermally into the lesion. Single photon
emission computed tomography (SPECT)
 obtained preoperatively can help to identify the
nodal basins at risk and, perhaps, the
 number and location of the sentinel nodes.
Intraoperatively, a handheld gamma probe is
 used to locate sentinel lymph nodes . PAG E 1
746
 30. For cutaneous squamous cell
carcinoma, which of the following
locations is considered a high-risk feature
for staging purposes?
 A. Junction of the ala and nasolabial fold
 B . Chin
 C. Ear
 D . Medial canthal area
 30. Answer: C. Primary tumor sites of the
ear and non-hair-bearing lip are high-risk
features
 for staging purposes. PAG E 1 728, TABLE
1 1 3.2
 31 . What is the most reliable method to
prevent pharyngeal spasm at the time of
primary tracheoesophageal {TE)
puncture?
 A. Single layer pharyngeal closure
 B. Botox inj ection
 C. Pharyngeal constrictor myotomy
 D. Pharyngeal neurectomy
 3 1 . Answer: C. Management of the
pharyngeal constrictor muscles to prevent
pharyngeal
 spasm is key to successful TE speech. The
most reliable method for preventing
spasm is a
 pharyngeal constrictor myotomy. PAG E 1
983
 32. Which of these melanoma subtypes is
also referred to as melanoma in situ?
 A. Superficial spreading
 B. Nodular
 C. Lentigo maligna
 D. Desmoplastic
 32. Answer: C. Lentigo maligna, also
known as melanoma in situ, is a
premalignant lesion
 that frequently develops in the head and
neck regions of elderly patients . PAG E 1
740
 3 3 . Patients who have undergone
chemoradiation are more likely to:
 A. Develop wound problems after salvage
surgery
 B. Develop deep vein thrombosis after
salvage surgery
 C. Develop local recurrence than if treated by
radiation alone
 D. Suffer free flap loss after salvage surgery
 E. Maintain their body weight during
treatment
 3 3 . Answer: A. The history of prior
chemoradiation is often associated with
worse performance,
 and poor nutritional status, fibrosis, and
small vessel thrombosis result in poor
 wound healing. PAG ES 1 708-1 709
 34. Which of the following statements is true?
 A. Osteogenic sarcomas, the most common arising from
the j aw in the head and neck, are primarily treated with
wide-field surgical excision with reconstruction followed by
adjuvant radiation for improved outcomes .
 B. Chondrosarcomas, arising from cartilaginous structures,
are treated with wide-field excision and postoperative
radiation if vital structures are involved.
 C. Rhabomyosarcomas of the paranasal sinuses are treated
with triple intrathecal chemotherapy, whole brain radiation,
and spinal radiation in both the pediatric and adult
populations.
 D. Fibrosarcomas, arising from fibroblasts, are treated with
induction chemoradiation, followed by wide-field radiation
 34. Answer: B . The primary therapy of
chondrosarcoma is wide local excision.
Osteogenic
 sarcoma may respond best to
chemoradiation. Adult rhabomyosarcoma
is treated with
 wide excision when possible. PAG ES
2047-2048
 3 5 . Which of the following arteries can
be a source of secondary hemorrhage or
major bleeding during transoral laser
resection of a supraglottic tumor?
 A. Inferior laryngeal artery
 B. Superior laryngeal artery
 C. Ascending pharyngeal artery
 D . Superior thyroid artery
 3 5 . Answer: B. The blood supply to the
supraglottic larynx is derived from the
superior laryngeal
 artery, a branch of the superior thyroid
artery. The superior laryngeal artery may be
 encountered while making tumor cuts in the
area of the lateral pharyngoepiglottic fold.
 Transecting this artery without prior ligation
can lead to retraction of the cut edge into the
 lateral soft tissues, causing bleeding. PAG ES
1 941 , 1 948
 3 6 . 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?
 A. MRI
 B. Administration of antireflux agents and speech
therapy
 C. Direct laryngoscopy with transoral laser
microsurgery (TLM) excisional biopsy
 D . Fiberoptic laryngoscopy after 1 month
 3 6 . Answer: C. Direct laryngoscopy with
TLM excision of the lesion gives a better
estimation
 of the depth of the lesion, improving
diagnostic yield, and has the option of
removing the
 entire gross lesion in the same setting.
Watchful waiting and/or conservative
treatment
 often leads to progression of disease. MRI is
not indicated in evaluation of a superficial
 supraglottic lesion. PAG E 1 950
 3 7 . 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?
 A. Branchial cleft cyst, previously infected
 B. Warthin tumor
 C. Lymphangioma
 D. Metastasis from the oropharynx
 3 7 . Answer: D. The surgeon must be alert to
those asymptomatic patients presenting with a
 cystic mass in the neck because it may be a
cystic metastasis. Positron emission
tomographycr
 may be helpful in detecting the occult primary in
the oropharynx. A branchial cleft cyst
 is less likely in this age group . Also, the
prevalence of human papillomavirus-related
cancers
 has changed the risk profile. PAG E 1 902
 3 8 . 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?
 A. Inferolateral
 B . Supralateral
 c. Inferomedial
 D . Supralateral
 3 8 . Answer: A. The ophthalmic artery is
inferolateral to the optic nerve. PAG E
2085
 3 9 . Merkel cell carcinoma is highly
specific for which of the following
immunostains?
 A. S l OO
 B. Synaptophysin
 C. CK-20
 D . Neuron-specific enolase
 3 9 . Answer: C. Merkel cells are of neural
crest origin and are highly specific for
cytokeratins to include CK-2 0 .
 40. Which of the following salivary gland
tumors is associated with the highest rate
of
 cervical metastases?
 A. Adenoid cystic cancer
 B. High-grade mucoepidermoid cancer
 C. Salivary duct cancer
 D. Squamous cell cancer
 40. Answer: C. Salivary duct cancer is a
highly aggressive malignancy with a high
rate of nodal
 metastases, present in more than 5 0 %
of patients at diagnosis. This tumor has a
poor
 prognosis due to a high rate of distant
metastatic disease. PAG E 1 767
 41 . The most common cause of false-
positive intraoperative parathyroid
hormone (IOPTH) is:
 A. Double adenoma
 B . Multigland hyperplasia
 C. Poor PTH clearance
 D. Renal compromise
 4 1 . Answer: A. Double adenomas are the
most common cause of false-positive
intraoperative
 PTH levels. The second adenoma may not be
biologically hypersecretory, and thus,
excision
 of one adenoma may result in a drop in
IOPTH to 5 0 % or less, but PTH levels will
 elevate postoperatively. PAG ES 2 1 38-2 1
39
 42 . 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
 D. Neither A nor B
 42 . Answer: C. A study of patients at MD
Anderson Cancer Center (201 2 ) revealed a
7%
 gastrostomy-tube rate 2 years after organ
preservation treatment for hypopharyngeal
 primaries. It was found that those patients
who were evaluated and treated by a team of
 speech pathologists, performed therapeutic
exercises, and maintained some oral intake
 through chemoradiation were less likely to be
PEG (percutaneous endoscopic gastrostomy)
 tube-dependent. PAG E 1 936
 43 . The following ultrasound features of a
thyroid nodule are associated with high
probability
 of malignancy except:
 A. Hyperechogenicity
 B. Hypoechogenicity
 C. Increased intranodular vascularity
 D. Microcalcification
 43 . Answer: A. Features of benign
nodules include coarse calcification,
regular margins, and
 pure cysts (hyperechogenicity) . PAG E 2
118
 44. Which statement is most accurate?
 A. Patients with orbital invasion rapidly develop ocular
symptoms, such as proptosis, diplopia, decreased
visual acuity, diminished motility, chemosis, lid
edema, and epiphora.
 B . Bone erosion of the lamina papyracea is an
absolute indication for orbital invasion.
 C. Resection of the inferior orbital wall, but not the
medial wall, produces enophthalmos and
hypophthalmos.
 D . To better restore the orbital anatomy and to
prevent lagophthalmos, due to ectropion, the lateral
canthus should be reattached 1 em superior to the
corresponding anatomical site of insertion
 44. Answer: A. Both cr and MRI may b e
required to quantify the extent of orbital
invasion,
 but bone erosion does not constitute an
absolute indication for exenteration. PAG
E 2057
 45 . Which of the following patients is
most likely to benefit from elective neck
dissection
 of levels I to IV?
 A. Tl No left true vocal fold
 B. T2No right true vocal fold
 C. T2No nasopharynx
 D . T2No right lateral tongue
 45 . Answer: D . More than 20% of early
stage oral tongue cancers harbor occult
nodal metastasis.
 The likelihood of occult nodal metastases
is higher for a T2 oral tongue cancer than
 for early stage glottic cancer, and
nasopharyngeal cancer is rarely treated
surgically.
 PAG ES 1 840-1 842
 46. Which of the following treatments is the
most appropriate therapy for a patient with a
T2N l human papillomavirus-positive
oropharyngeal cancer?
 A. Induction chemotherapy with docetaxel,
cisplatin, and 5 -FU followed by radiotherapy
 B. Concurrent chemoradiation with cisplatin
and cetuximab
 C. Radiation therapy only
 D . Concurrent chemoradiation with cisplatin
and 5 -FU
 46. Answer: C. The subset of patients
with T1 or T2 oropharyngeal cancer and N
1 disease,
 while considered stage III disease, do not
appear to benefit from the addition of
chemotherapy
 to radiation therapy. These patients may
be treated with radiation alone.
 PAG E 1 698
 47. What is the most commonly
encountered cause for squamous cancer
of the tongue base?
 A. Tobacco exposure
 B. Human papillomavirus (HPV) type 1 6
infection
 C. Second-hand smoke
 D. Chronic alcohol use
 47. Answer: B. Studies have found that oral HPV
infection is strongly associated with squamous
 cell carcinoma (SCCA) of the oropharynx in those
patients with and without risk
 factors of alcohol and tobacco use. In addition, it
was found that there is a 1 4-fold increase
 in risk of developing SCCA of the oropharynx in
those patients who are seropositive for
 HPV 1 6 . The incidence of tobacco-related
tongue base cancer has decreased, while the
 incidence of HPV-associated tongue base cancer
is rising. PAG E 1 900
48. After completion of chemotherapy and
radiotherapy for T2N2B HPV squamous cell
carcinoma of the left tonsil, what initial
follow-up would you recommend?
 A. cr of neck 2 to 3 months after treatment
 B. Staging tonsillectomy 2 to 3 months after
treatment
 C. Modified left neck dissection 2 to 3 months
after treatment
 D. Positron emission tomography (PET)/CT 3
months after treatment
 48. Answer: D. PET-Cf is recommended at 1
2 weeks posttreatment to evaluate for
residual
 disease. The primary tumor and/ or neck are
treated accordingly. Staging tonsillectomy
 and/or neck dissection 2 to 3 months
posttreatment are not indicated unless there
is clinical
 (physical examination, PET-Cf) evidence of
disease. PAG E 1 904
 49. Which of the following is not an indication
for radioactive iodine treatment?
 A. Tl NOMO thyroid papillary carcinoma, 3 0-
year-old women
 B. Pulmonary metastasis from papillary
thyroid carcinoma
 C. 4-cm papillary thyroid carcinoma with
extrathyroidal extension
 D. 70-year-old man with 2-cm papillary
thyroid carcinoma treated with total
thyroidectomy
 49. Answer: A. Low risk is characterized
by age less than 45, absence of cervical
metastasis,
 absence of local invasion, and low-grade
histology. PAG E 2 1 25
 50. What is the principal difference in
oncological resection technique between
transoral laser resection and classic
oncological surgery?
 A. Smaller enbloc tumor margins
 B . Inability to visualize the deep margins
 C. Transtumoral cut and multibloc
resection
 D . Frozen section analysis of resection
margins
 50. Answer: C. Transoral laser microsurgery
(TLM) utilizes transtumoral cuts to assess the
 depth of the tumor and multibloc resection as
opposed to an enbloc tumor resection which
 http://medical.dentalebooks.com
 Chapter 7: Head and Neck Surgery 21 7
 is utilized in open techniques where there is
wide exposure of the tumor. The transoral
 approach allows histologic clearing of tumor
margins while the anatomy and functional
 integrity of the noninvolved tissue is spared