Vascular & Lymphatic INBDE Patient Cases

Question 1

The PSA block targets which anatomic region?

Accepted Answer

D. Posterior surface of the maxilla above the second molar, The PSA block deposits anesthetic posterior and superior to the maxillary tuberosity, near where the PSA branches enter the bone above the apex of the maxillary second molar. The needle is angled up, in, and back about 45 degrees from the occlusal plane.

Answer

A. Mandibular foramen on the medial ramus

Answer

B. Greater palatine foramen

Answer

C. Mental foramen

Question 2

Which venous structure lies in the path of an over-advanced PSA needle?

Accepted Answer

D. Pterygoid venous plexus, The pterygoid venous plexus is a dense, valveless network around the lateral pterygoid muscle in the infratemporal fossa, directly behind the maxillary tuberosity. A PSA needle advanced too far posteriorly enters this plexus and produces a rapid, diffuse hematoma.

Answer

A. Internal jugular vein

Answer

B. Facial vein at the mandibular border

Answer

C. Cavernous sinus

Question 3

Why does pterygoid plexus injury produce a hematoma so quickly?

Accepted Answer

A. The plexus is valveless and densely interconnected, The pterygoid plexus is a low-pressure but valveless venous network surrounding the lateral pterygoid. Without valves, blood spreads freely through interconnected channels once any vessel is punctured, producing diffuse swelling within minutes.

Answer

B. Maxillary bone resorbs after needle contact

Answer

C. Lidocaine causes immediate vessel rupture

Answer

D. The plexus contains high-pressure arterial flow

Question 4

What is the most appropriate immediate management?

Accepted Answer

D. Apply pressure and ice, postpone treatment, monitor, Pterygoid plexus hematomas are self-limited. Apply firm extraoral pressure, ice for the first 24 hours, then warm compresses, soft diet, and NSAIDs. Postpone elective treatment, document, and reassure that ecchymosis migrates inferiorly over 1 to 2 weeks before resolving.

Answer

A. Incise and drain the cheek swelling

Answer

B. Start IV antibiotics empirically

Answer

C. Activate EMS for airway concern

Question 5

Which technique modification best reduces the risk of pterygoid plexus injury on the next PSA block?

Accepted Answer

B. Limit penetration to about 16 mm and aspirate before injecting, Limiting needle depth to approximately 16 mm (about three-quarters of a short needle) and aspirating in two planes before depositing anesthetic prevents over-insertion into the plexus and detects intravascular placement. Slow deposition further reduces vessel trauma.

Answer

A. Inject rapidly to outrun bleeding

Answer

C. Use a long 25-gauge needle to full depth

Answer

D. Aim more posteriorly to ensure block depth

Question 6

Anterior epistaxis most commonly originates from which vascular site?

Accepted Answer

A. Kiesselbach plexus on the anterior nasal septum, Kiesselbach plexus (Little's area) is an anastomosis on the anteroinferior nasal septum where branches from the anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries meet. It is the source of about 90 percent of anterior nosebleeds.

Answer

B. Internal carotid artery within the cavernous sinus

Answer

C. Pterygoid venous plexus

Answer

D. Sphenopalatine artery in the posterior nasal cavity

Question 7

Which artery is the dominant source of posterior epistaxis and a branch of the maxillary artery?

Accepted Answer

B. Sphenopalatine artery, The sphenopalatine artery is the terminal branch of the maxillary artery in the pterygopalatine fossa. It enters the nasal cavity through the sphenopalatine foramen and is the main source of brisk posterior nosebleeds, which run down the throat rather than out the nostril.

Answer

A. Anterior ethmoidal artery

Answer

C. Greater palatine artery

Answer

D. Superior labial artery

Question 8

Which feature most strongly differentiates posterior from anterior epistaxis?

Accepted Answer

A. Blood runs down the posterior pharynx, Posterior epistaxis from the sphenopalatine territory drains backward down the pharynx rather than out the nares, and is often heavier, harder to control with pinching, and may require nasal packing or ENT intervention. This patient's anterior-only drip pattern points to Kiesselbach.

Answer

B. Visible clot on the anterior septum

Answer

C. Bleeding stops with five minutes of pinching

Answer

D. Blood drips out of the nostril

Question 9

What is the most appropriate immediate management of his bleeding history before any dental treatment today?

Accepted Answer

B. Refer to the prescribing physician to check INR and adjust dosing, Recurrent bleeding with a recent INR of 3.8 is supratherapeutic and not the dentist's adjustment to make. Contact the prescribing physician for INR recheck and dose adjustment before elective dental treatment. Routine cleaning is generally safe at therapeutic INR but should be deferred while INR is high.

Answer

A. Prescribe tranexamic acid mouthwash and continue

Answer

C. Have the patient hold warfarin for one week and reappoint

Answer

D. Proceed with cleaning and ignore the INR

Question 10

Which combination of arteries contributes to Kiesselbach plexus?

Accepted Answer

C. Anterior ethmoidal, sphenopalatine, greater palatine, superior labial, Kiesselbach plexus is fed by branches from both the internal carotid (anterior ethmoidal) and external carotid (sphenopalatine, greater palatine, superior labial) systems. This dual supply on a thin septal mucosa is why it bleeds so readily from minor trauma or dryness.

Answer

A. Lingual, facial, occipital, ascending pharyngeal

Answer

B. Internal carotid only

Answer

D. Inferior alveolar, mental, mylohyoid, lingual

Question 11

The lateral tongue and floor of mouth drain first to which nodal level?

Accepted Answer

C. Level Ib (submandibular), Level Ib (submandibular nodes) is the first-echelon drainage for the lateral tongue, floor of mouth, and most teeth except mandibular incisors and third molars. Onward drainage proceeds to the upper deep cervical chain (level II).

Answer

A. Level V (posterior triangle)

Answer

B. Parotid (preauricular)

Answer

D. Level Ia (submental)

Question 12

Level Ib is anatomically bounded by which structures?

Accepted Answer

A. The anterior and posterior bellies of digastric and the mandibular body, Level Ib is the submandibular triangle, bounded by the anterior belly of digastric medially, the posterior belly of digastric posteriorly, and the inferior border of the mandible superiorly. The submandibular gland sits within this triangle alongside level Ib nodes.

Answer

B. The hyoid bone and the cricoid cartilage

Answer

C. The mastoid and the styloid process

Answer

D. The clavicle and the sternocleidomastoid

Question 13

Which node features are most concerning for metastatic carcinoma in this patient?

Accepted Answer

A. Firm, fixed, non-tender, persistent more than 2 weeks, Firm, fixed, non-tender, persistent cervical lymphadenopathy in an adult with smoking, alcohol use, and a suspicious oral lesion is highly concerning for metastatic squamous cell carcinoma. Reactive nodes are typically soft, mobile, tender, and resolve within a few weeks.

Answer

B. Small shotty nodes after a viral illness

Answer

C. Pulsatile and compressible

Answer

D. Soft, mobile, tender, warm

Question 14

What is the most appropriate next step?

Accepted Answer

D. Refer urgently for biopsy and staging, Any oral ulcer persisting beyond 2 to 3 weeks, especially with a suspicious cervical node and risk factors, warrants urgent referral to OMFS or ENT for biopsy and staging. Delay is the most common avoidable contributor to advanced-stage disease at diagnosis.

Answer

A. Reassess in 3 months

Answer

B. Prescribe chlorhexidine and antibiotics

Answer

C. Excise the neck node in the dental office

Question 15

If this primary metastasizes further, what is the next nodal station along the expected lymphatic route?

Accepted Answer

C. Upper deep cervical chain (level II, jugulodigastric), From level Ib, lateral tongue lymph proceeds to the upper deep cervical chain along the internal jugular vein, with the jugulodigastric (tonsillar) node at level II as a classic next stop. All head and neck lymph ultimately converges on the deep cervical chain.

Answer

A. Parotid nodes

Answer

B. Occipital nodes

Answer

D. Retropharyngeal nodes

Question 16

Which artery is the most likely source of this pulsatile bleed?

Accepted Answer

D. Sublingual artery, a branch of the lingual artery, The sublingual artery branches from the lingual artery and runs forward on the superior surface of the mylohyoid, supplying the floor of mouth and sublingual gland. Deep dissection medial to the sublingual caruncle during frenectomy is the classic mechanism of injury.

Answer

A. Inferior alveolar artery

Answer

B. Facial artery at the mandibular notch

Answer

C. Maxillary artery

Question 17

Where does the lingual artery typically lie relative to the hyoglossus muscle?

Accepted Answer

A. Deep (medial) to hyoglossus, The lingual artery passes deep (medial) to the hyoglossus muscle, while the lingual nerve, submandibular duct, and hypoglossal nerve cross superficial (lateral) to hyoglossus. This separation is the anatomic basis for ligating the lingual artery posterior to hyoglossus during head and neck surgery.

Answer

B. Lateral to hyoglossus, alongside the lingual nerve

Answer

C. Within the substance of genioglossus

Answer

D. Superficial to mylohyoid

Question 18

Why is deep dissection medial to the sublingual caruncle particularly risky?

Accepted Answer

D. It risks injury to the submandibular duct and sublingual artery, The sublingual caruncle marks the opening of Wharton's duct, and the sublingual artery and lingual nerve run nearby in a thin floor of mouth. Deep blind cuts here risk both brisk bleeding (sublingual artery) and salivary duct injury, which is why frenectomy should stay superficial and midline.

Answer

A. It risks injury to the maxillary sinus

Answer

B. It risks injury to the parotid duct

Answer

C. It risks injury to the facial nerve

Question 19

What is the most appropriate immediate management?

Accepted Answer

C. Apply firm bimanual pressure and place a deep suture for hemostasis, Immediate bimanual compression (one finger intraoral, one submental) controls most floor-of-mouth bleeding while a suture is placed at the bleeding site. If bleeding does not stop or a hematoma expands, transfer to an oral surgeon or emergency department for definitive control.

Answer

A. Continue dissection to find the bleeder

Answer

B. Give oral tranexamic acid and observe

Answer

D. Pack the floor of mouth and discharge home

Question 20

What sign would change disposition from office management to immediate hospital transfer?

Accepted Answer

B. Expanding sublingual swelling with tongue elevation or voice change, An expanding sublingual hematoma can elevate the tongue and obstruct the supraglottic airway within minutes, mimicking Ludwig's angina. Any tongue elevation, muffled voice, drooling, or stridor mandates immediate EMS activation, airway protection, and hospital transfer.

Answer

A. A small clot at the wound

Answer

C. Mild postoperative discomfort

Answer

D. Transient anxiety

Question 21

The common carotid artery typically bifurcates at approximately what level?

Accepted Answer

B. C4, at the upper border of the thyroid cartilage, The common carotid bifurcates at about C4, at the upper border of the thyroid cartilage, into the internal and external carotid arteries. The carotid bulb at this level contains baroreceptors and is the classic site of atherosclerotic plaque.

Answer

A. C7

Answer

C. C2

Answer

D. T1

Question 22

Which statement reliably distinguishes the internal from the external carotid artery in the neck?

Accepted Answer

B. The ICA gives off no branches in the neck, The internal carotid gives off no branches in the neck; its first branches arise intracranially (ophthalmic artery and beyond). The external carotid, by contrast, gives off eight branches in the neck and face before terminating as the maxillary and superficial temporal arteries.

Answer

A. The ICA always lies anterior to the ECA at the bifurcation

Answer

C. The ECA terminates in the circle of Willis

Answer

D. The ECA has no branches above the mandible

Question 23

What does a carotid bruit at the angle of the mandible most likely reflect?

Accepted Answer

A. Turbulent flow through atherosclerotic narrowing at the carotid bifurcation, An audible bruit at the bifurcation typically reflects turbulent flow through an atherosclerotic stenosis at the carotid bulb. It is associated with increased stroke risk, particularly in patients with vascular risk factors like this one.

Answer

B. Thyroid hyperfunction

Answer

C. Referred cardiac murmur

Answer

D. Normal venous hum

Question 24

What is the most appropriate disposition from the dental office?

Accepted Answer

B. Defer elective dental work and refer to the primary physician for evaluation, including carotid duplex ultrasound, A newly discovered carotid bruit in a patient with vascular risk factors warrants medical referral for stroke risk assessment, typically with carotid duplex ultrasound. Elective dental treatment should be deferred until evaluation is complete; urgent care for true dental emergencies can proceed with medical input.

Answer

A. Order a CT angiogram from the dental office

Answer

C. Proceed with crown preparation today

Answer

D. Place the patient on aspirin and reappoint next week

Question 25

If this patient later develops sudden right-sided weakness and aphasia in the dental chair, what is the immediate priority?

Accepted Answer

A. Activate EMS for stroke protocol and note the time of symptom onset, Acute focal neurologic deficits in a patient with known vascular risk are presumed stroke until proven otherwise. Time of last-known-normal drives thrombolysis eligibility, so the dentist's job is to activate EMS immediately, document onset, and protect the airway during transfer.

Answer

B. Administer oxygen and reschedule

Answer

C. Give an aspirin and observe for an hour

Answer

D. Lay the patient flat and check blood glucose only

Question 26

What is the vascular route by which this canine-space infection seeds the cavernous sinus?

Accepted Answer

B. Facial vein → superior and inferior ophthalmic veins → cavernous sinus, The facial vein in the danger triangle communicates retrograde with the cavernous sinus through the superior and inferior ophthalmic veins, which lack effective valves. Bacteremia from a manipulated lip infection can therefore deposit septic emboli intracranially.

Answer

A. Pterygoid venous plexus → maxillary vein → cavernous sinus

Answer

C. Lymphatic spread via submental nodes → deep cervical chain → dural venous sinuses

Answer

D. Facial artery → internal carotid artery → cavernous sinus

Question 27

Which cranial nerve is NOT typically involved in cavernous sinus thrombosis?

Accepted Answer

B. CN VII (facial), The cavernous sinus contains CN III, IV, V1, V2, and VI. CN VII does not pass through it, so facial weakness in this setting suggests a different process (Bell's palsy, parotid pathology, brainstem stroke).

Answer

A. CN III (oculomotor)

Answer

C. CN VI (abducens)

Answer

D. CN V1 (ophthalmic division of trigeminal)

Question 28

Why do midface danger-triangle infections reach the cavernous sinus more easily than lower-face infections?

Accepted Answer

C. Veins of the danger triangle are valveless, allowing retrograde flow, The facial vein and its tributaries draining the danger triangle (upper lip, nose, medial cheek) lack effective valves. When local pressure rises or thrombosis forms, blood and bacteria can flow backward through the ophthalmic veins into the cavernous sinus.

Answer

A. The facial vein has competent valves that prevent reversal of flow

Answer

B. Arterial pressure in the upper face is higher

Answer

D. Lymphatic drainage from the upper lip is unidirectional

Question 29

What is the most appropriate disposition from the dental office?

Accepted Answer

D. Activate EMS for emergency hospital transfer for IV antibiotics, imaging, and ophthalmology consult, Cavernous sinus thrombosis is a true emergency. The patient needs contrast MR venography or CT venography, broad-spectrum IV antibiotics covering Staphylococcus aureus, anticoagulation in selected cases, and ophthalmology plus neurosurgery input. Mortality remains significant even with treatment.

Answer

A. Incise and drain the upper-lip lesion in the office

Answer

B. Prescribe oral amoxicillin and reassess in 48 hours

Answer

C. Refer to a primary care office for next-day evaluation

Question 30

Which odontogenic source carries the highest risk of cavernous sinus thrombosis?

Accepted Answer

C. Maxillary anterior or premolar periapical abscess tracking to the canine space, Maxillary anterior and premolar infections can track up through the canine space into the periorbital and infraorbital tissues, then drain via the angular vein into the ophthalmic veins. This is the odontogenic analogue of the upper-lip route to the cavernous sinus.

Answer

A. Submental space cellulitis

Answer

B. Mandibular incisor periapical abscess

Answer

D. Lower third molar pericoronitis

Question 31

The lower lip and chin drain first to which lymph node group?

Accepted Answer

B. Submental nodes (level Ia), The lower lip, chin, tip of tongue, and mandibular incisors drain first to the submental (level Ia) nodes. Onward flow reaches the submandibular (Ib) and upper deep cervical (level II) chains.

Answer

A. Retropharyngeal nodes

Answer

C. Parotid nodes

Answer

D. Submandibular nodes (level Ib)

Question 32

Level Ia (submental triangle) is bounded by which structures?

Accepted Answer

D. The anterior bellies of digastric and the hyoid bone, with mylohyoid as the floor, The submental triangle is bounded laterally by the anterior bellies of digastric and inferiorly by the hyoid bone, with mylohyoid as its floor. Level Ia nodes and small submental veins sit here.

Answer

A. The clavicle and the trapezius

Answer

B. The mastoid process and the styloid process

Answer

C. The mandible and the sternocleidomastoid

Question 33

Why is a midline lower-lip cancer of particular staging concern?

Accepted Answer

C. Midline lesions can drain bilaterally, putting nodes on both sides at risk, Midline structures (lower lip, tongue tip, midline floor of mouth) have bilateral lymphatic drainage, so a midline cancer can seed nodes on either side. This is why bilateral neck imaging or dissection is considered for midline lesions.

Answer

A. Midline lesions metastasize through the facial artery directly

Answer

B. Midline lesions invade the maxillary sinus

Answer

D. Midline lesions spread only hematogenously

Question 34

Which features make this submental node concerning rather than reactive?

Accepted Answer

A. Firm, non-tender, persistent, in a sun-exposed older patient with a non-healing lip lesion, Firm, non-tender, persistent cervical nodes in an older patient with risk factors and a suspicious primary are red flags for metastatic carcinoma. Reactive nodes are usually soft, tender, mobile, and resolve within weeks.

Answer

B. Bilateral tender lymphadenopathy with sore throat

Answer

C. Small shotty nodes after a viral illness

Answer

D. Soft, tender, mobile, transient

Question 35

What is the most appropriate next step?

Accepted Answer

B. Incisional biopsy of the lip lesion and urgent referral to oral surgery or ENT for staging, A non-healing lip ulcer plus a suspicious cervical node warrants incisional (not excisional) biopsy of the primary plus urgent referral for staging imaging and definitive management. Diagnosing the primary first preserves surgical planning options.

Answer

A. Aspirate the lip lesion and start oral antibiotics

Answer

C. Office excision of the submental node alone

Answer

D. Topical antifungal cream and recheck in 6 weeks

Question 36

Which lymph nodes are the first-station drainage for maxillary third molars?

Accepted Answer

C. Retropharyngeal, Maxillary third molars, soft palate, and posterior pharynx drain to retropharyngeal nodes before reaching the deep cervical chain. This is the lymphatic exception worth remembering when a posterior maxillary infection has a normal submandibular exam.

Answer

A. Submandibular (Ib)

Answer

B. Submental (Ia)

Answer

D. Parotid

Question 37

Why is retropharyngeal spread from a posterior maxillary infection clinically dangerous?

Accepted Answer

A. The retropharyngeal space communicates inferiorly with the mediastinum, The retropharyngeal space extends from the skull base inferiorly to the mediastinum (often via the danger space behind it). Infection can therefore descend into the chest, causing descending necrotizing mediastinitis, a life-threatening complication.

Answer

B. The retropharyngeal space contains the carotid bulb

Answer

C. The retropharyngeal space drains into the submental triangle

Answer

D. The retropharyngeal space communicates with the cavernous sinus

Question 38

Which imaging study best evaluates the extent of this infection?

Accepted Answer

D. Contrast-enhanced CT of the neck, Contrast CT of the neck is the standard for suspected deep neck space infection. It maps the spaces involved, identifies drainable collections, and assesses airway compromise. A panoramic film cannot evaluate soft tissue spaces.

Answer

A. Periapical radiograph of the third molar

Answer

B. Panoramic radiograph alone

Answer

C. Plain lateral neck film

Question 39

What is the most appropriate disposition from the dental office?

Accepted Answer

C. Immediate transfer to a hospital with OMFS and ENT capability for IV antibiotics, imaging, and possible drainage, Trismus, fever, posterior pharyngeal bulging, and a muffled voice indicate deep space involvement and possible airway risk. The patient needs IV antibiotics, urgent CT, and possible operative drainage, none of which belong in an outpatient dental office.

Answer

A. Defer treatment until symptoms improve

Answer

B. Prescribe oral antibiotics, warm compresses, and recheck in 48 hours

Answer

D. Extract the tooth in the office and prescribe amoxicillin

Question 40

Which sign most strongly suggests impending airway compromise requiring immediate airway protection?

Accepted Answer

C. Stridor, drooling, or tripod positioning, Stridor, drooling, and the tripod position signal critical narrowing of the supraglottic airway. They prompt immediate airway management (typically awake fiberoptic intubation or surgical airway) before any other intervention.

Answer

A. Painful swallowing without fever

Answer

B. Mild trismus

Answer

D. Cheek swelling without warmth

Question 41

Which artery is the most likely intraosseous source of socket bleeding after a lower first molar extraction?

Accepted Answer

D. Inferior alveolar artery and its dental branches in the mandibular canal, The inferior alveolar artery and its dental branches run with the IAN in the mandibular canal and supply the mandibular molars. After extraction, the dental branch and inter-radicular alveolar bone are the typical bleeding source within the socket.

Answer

A. Sublingual artery on the floor of mouth

Answer

B. Facial artery at the mandibular border

Answer

C. Maxillary artery in the infratemporal fossa

Question 42

What is the most appropriate first-line local hemostatic strategy?

Accepted Answer

D. Place a hemostatic agent in the socket, suture with a figure-eight, and apply moist gauze pressure, Local measures are the dentist's first response: irrigate, place a hemostatic (oxidized regenerated cellulose, gelatin sponge, or collagen plug), close with a figure-eight or interrupted suture, and apply pressure with moist gauze. Tranexamic acid mouthwash is a useful adjunct.

Answer

A. Cauterize the socket with electrocautery

Answer

B. Apply topical epinephrine 1:1000 directly into the socket

Answer

C. Pack with dry gauze and instruct the patient to bite overnight

Question 43

Should this patient routinely stop apixaban for a future simple extraction?

Accepted Answer

C. No, current guidelines generally recommend continuing DOACs for simple extractions with effective local hemostasis, For simple extractions, current guidance (ADA, SDCEP) recommends continuing DOACs with effective local hemostasis, because the stroke risk of interrupting anticoagulation usually outweighs the bleeding risk. Any change in dosing is the prescribing physician's decision, not the dentist's alone.

Answer

A. Replace apixaban with daily aspirin permanently

Answer

B. Yes, hold apixaban for 5 days before any dental procedure

Answer

D. Stop apixaban only if the INR is above 3

Question 44

If local measures and tranexamic mouthwash fail after 30 to 60 minutes, what is the next appropriate step?

Accepted Answer

C. Transfer to the emergency department for further evaluation and possible reversal, Failure of local measures plus an antifibrinolytic in an anticoagulated patient warrants ED transfer. Hospital options include further mechanical control, andexanet alfa or 4-factor PCC for life-threatening apixaban bleeding, and labs to assess blood loss.

Answer

A. Administer vitamin K in the office

Answer

B. Send the patient home with more gauze

Answer

D. Prescribe oral iron and observe

Question 45

Which laboratory test best reflects apixaban's anticoagulant effect when needed?

Accepted Answer

B. Anti-Xa activity calibrated to apixaban, Apixaban is a factor Xa inhibitor. Calibrated chromogenic anti-Xa assays measure its activity; PT/INR and aPTT are unreliable. Routine monitoring is not required, but anti-Xa is useful in emergencies and before urgent surgery.

Answer

A. Platelet count

Answer

C. INR

Answer

D. Bleeding time

Question 46

Which nodal level contains the upper deep cervical (jugulodigastric) node, the classic landing site for tonsillar drainage?

Accepted Answer

C. Level II (upper deep cervical), Level II encompasses the upper deep cervical chain along the IJV, from the skull base to the level of the hyoid. The jugulodigastric (tonsillar) node sits in level II and is a typical first metastatic stop for oropharyngeal cancers.

Answer

A. Level IV (lower deep cervical, supraclavicular)

Answer

B. Level Ia (submental)

Answer

D. Level V (posterior triangle)

Question 47

Referred otalgia in this patient most likely reflects shared innervation from which cranial nerve to the oropharynx and middle ear?

Accepted Answer

A. CN IX, with contribution from the auriculotemporal branch of V3, Pain from the tonsil and base of tongue is carried by CN IX, which also gives middle-ear sensation via Jacobson's nerve, producing referred otalgia. The auriculotemporal nerve (V3) adds external ear sensation and overlaps the referral pattern. Unexplained unilateral ear pain in an adult smoker is a red flag for oropharyngeal cancer.

Answer

B. CN XII

Answer

C. CN V

Answer

D. CN VII

Question 48

Which workup is most appropriate next?

Accepted Answer

A. Urgent ENT referral for endoscopy, contrast imaging, and image-guided FNA of the node, The standard pathway is ENT referral for flexible endoscopy of the upper aerodigestive tract, contrast CT or MRI of the neck, and fine-needle aspiration of the node. Open excision of an unknown primary's metastatic node disrupts staging and surgical fields and is no longer the first step.

Answer

B. Open excisional biopsy of the neck node in the dental office

Answer

C. Empiric oral antibiotics for 2 weeks, then recheck

Answer

D. Reassure and have the patient return in 6 months

Question 49

If biopsy confirms p16-positive squamous cell carcinoma of the tonsil, what does that imply?

Accepted Answer

A. Likely HPV-associated, with generally better prognosis than HPV-negative SCC, p16 positivity is a surrogate for HPV-driven (typically HPV-16) oropharyngeal SCC, which presents in younger and often non-smoking patients with cystic level II nodes and has substantially better treatment response and survival than HPV-negative disease.

Answer

B. Likely radiation-induced, with limited treatment options

Answer

C. Likely smoking-driven only, with worse prognosis

Answer

D. Likely a benign lymphoid proliferation

Question 50

Which finding would shift the dentist's role from diagnostic referral to immediate airway concern?

Accepted Answer

D. Progressive trismus, stridor, drooling, or a muffled "hot potato" voice, Stridor, drooling, trismus, and a muffled "hot potato" voice signal impending airway obstruction from a large oropharyngeal mass or parapharyngeal extension. These findings require EMS activation and ENT/anesthesia airway management, not outpatient referral.

Answer

A. Mild referred otalgia

Answer

B. Painless 2 cm node persistent for 8 weeks

Answer

C. Stable vital signs and a normal voice

Vascular & Lymphatic INBDE Patient Cases

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