• A: Most malignant tumours are adenocarcinomas
• B: Alcohol consumption is a risk factor
• C: The root of the mouth is the commonest site
• D: Neck nodes are only treated in T4 tumours
• E: Both sides of the neck may need to be treated in a unilateral carcinoma

Answer: B & E

Explanation: Most malignant tumours of the oral cavity are squamous cell carcinomas. Alcohol consumption and smoking are risk factors. The commonest sites are the lateral border of the tongue and the floor of the mouth. In almost all cases of oral carcinoma, treatment should be given to the neck nodes in the form of radiotherapy or a node dissection. Treatment to both sides of the neck may be necessary, given the extensive crossover of lymph node drainage from the oral cavity area.

• A: More cysts lie on the left than on the right.
• B: There is a role for radio-iodine scanning
• C: They move with swallowing because they are attached to the hyoid
• D: They may be confused on clinical examination with a dermoid cyst
• E: Sistrunk’s procedure includes excision of a wedge of hyoid bone
• F: Recurrence after Sistrunk’s procedure is 30%.

Answer: A, B, D & E.

Explanation: The thyroglossal cysts lie along the track of the obliterated thyroglossal tract, and most lie in the midline- however, 9% lie on left and 1% on the right. They may contain elements of thyroid tissue. A technetium or radio-iodine scan may therefore confirm the diagnosis, although an ultrasound scan may also be used. Clinically, hey move with both swallowing and tongue protrusion, as they are attached to the thyroglossal tract remnant and the larynx – however a dermoid cyst is attached to the hyoid bone may be misdiagnosed as a thyroglossal cyst. The operation of choice is Sistrunk’s operation, which involves excision of the whole of the tract together with the median third of the hyoid bone. If this is done, the recurrence rate should be < 10%.

• A: They may arise from squamous epithelial remnant
• B: 60% present on the right side
• C: 60% present in men
• D: 25% cysts become infected
• E: They lie posterior to the sternocleidomastoid muscle

Answer: A, C & D

Explanation: There are many theories regarding the origin of branchial cysts, but the most popular one at present suggests that islands of squamous epithelium within lymph nodes cause their formation. They usually present in young adults, with 60% on the left side and 60% in men. They lie deep to anterior border of the sternocleidomastoid muscle, at the junction of the upper third and middle two-thirds. Infection occurs in a quarter (25%) of cases, and excision is indicated when inflammation has settled.

• A: are more common at high altitude
• B: should be biopsied by FNA
• C: are best investigated by CT
• D: may present as glomus jugulare tumours.

Answer: A, B &D

Explanation: Chemodectomas arise from nerve tissue on the medial side of the carotid bulb (carotid body tumours), from the vagus nerve (glomus vagale tumours) or the ganglion nodosum just below the jugular foramen  (glomus jugulare tumours). Carotid body tumours are common at high altitude, eg. In Bolivia. They are almost always benign, although mass effects may lead to pressure on skull base structures. An arteriogram is the first-line investigation, and it often shows a splayed carotid bifurcation. If necessary, it may be possible to resect the tumour, with graft replacement of the involved artery portion if required.

• A: Movable multiple ipsilateral nodes < 6 cm indicate an N2a tumour stage
• B: In approximately 5 – 10 % of cases the primary remains elusive
• C: N1 nodes may be treated solely by radiotherapy
• D: In N2 tumours, postoperative radiotherapy increases survival.

Answer: B & C

Explanation: Neck nodes are divided into various levels, and their enlargement from neoplasia can be classified by the UICC system as follows:
N0 – regional nodes snot palpable
N1 – Movable single ipsilateral or bilateral nodes < 3 cm
N2 – Movable ipsilateral or bilateral nodes.

• a – Single ipsilateral node 3 -6 cm diameter
• b – Multiple ipsilateral nodes < 6 cm diameter
• c – Bilateral or contralateral nodes < 6 cm diameter

N3 – nodes > 6 cm.
After careful search, up to 10% of patients have no identifiable primary source. Treatment will depend to some extent on the primary, but N1 nodes may be treated by radiotherapy alone, although some prefer a modified neck dissection. N2 is an indication for a neck dissection, and N3 may indicate the need for a palliative procedure.

• A: It is important to apply a tight head dressing post-pinnaplasty
• B: Facial animation is not usually considered until 1 year after facial palsy onset
• C: Facelifts involve elevation of the superficial muscle and aponeurotic system

Answer: B & C

• A: Most tumours are adenocarcinomas
• B: There is a strong association with tobacco and alcohol
• C: There is an association with Plummer-Vinson-Patterson-Kelly (PVPK) syndrome
• D: A tumour > 4 cm in diameter with no invasion of adjacent structures is a T3 tumour.
• E: Small tumours may be treated by watchful waiting
• F: Patients rarely require calcium or thyroxine after surgery 

Answer: C & D 

Explanation: About 90% of hypopharyngeal tumours are squamous cell carcinomas. A strong association with tobacco and alcohol has not yet been proven, in contrast to other upper aerodigestive tract tumours. There is, however, an association with PVPK syndrome, in that 25 of patients with the disease will suffer postcricoid carcinoma. Staging is similar to other carcinomas, in that a tumour > 4 cm diameter is classified as T3. Watchful waiting is not an option with hypopharyngeal tumours – patients will always require some treatment to the neck if a cure is to be achieved. Surgical resection usually involves some permanent derangements of thyroid or parathyroid hormones, and patients often require lifelong supplementation.

• A: Hoarseness is the most common feature
• B: A fixed vocal cord indicates a T2 tumour
• C: Glottis tumours metastasize early from extensive lymph node drainage
• D: A total laryngectomy usually includes a thyroidectomy

Answer: A & D

Explanation: The most common feature of laryngeal carcinoma is hoarseness, although dyspnea and stridor may eventually also be present. Staging usually requires direct visualization of the tumour via panendoscopy- a fixed vocal cord in supraglottic or glottis tumours indicate a t3 lesion. Glottis tumours rarely metastasize until they have spread superiorly or inferiorly, as the glottis has only limited lymph drainage. Smaller lesions may be treated by radiotherapy alone, but larger ones often require a neck dissection combined with a total laryngectomy, which includes removal of the thyroid gland.

• A: often involves the fossa of Rosenmuller
• B: is associated with infectious mononucleosis
• C: is often treated with surgery
• D: typically affects young women in the case of angiofibromas
• E: always involves the sphenopalatine foramen in the case of angiofibroma

Answer: A, B & E

Explanation: Nasopharyngeal carcinoma usually arises from the fossa of Rosenmuller. Highest incidence is in Southern Chinese people, with the Epstein-Barr virus and salted preserved fish being implicated as causal agents. Radiotherapy is the treatment of choice, although a radical neck dissection may occasionally be necessary.
Angiofibroma is a benign tumour made up of vascular tissue and arising from the back of the nose. It affects young men, and always involves the sphenopalatine foramen; indeed this may be the site of origin.