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OMS practice questions

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Question 1Oral and Maxillofacial Surgery

A patient sustains a mandibular angle fracture. Which muscle group most commonly displaces the proximal segment medially and superiorly?

  1. Lateral pterygoid and digastric
  2. Geniohyoid and genioglossus
  3. Medial pterygoid, masseter, and temporalis Correct answer.
  4. Orbicularis oris and buccinator

Explanation

The proximal segment of an angle fracture is pulled medially, superiorly, and anteriorly by the elevator muscles-medial pterygoid, masseter, and temporalis-which insert on the ramus. The depressor and suprahyoid muscles act mainly on the distal segment.

Question 2Oral and Maxillofacial Surgery

Which of the following best describes the primary advantage of rigid internal fixation with plates and screws after bilateral sagittal split osteotomy?

  1. It removes the need for preoperative orthodontics
  2. It permits early mobilization without maxillomandibular fixation Correct answer.
  3. It guarantees permanent anesthesia of the lower lip
  4. It eliminates the need for any postoperative imaging

Explanation

Rigid internal fixation stabilizes the osteotomy segments so that patients can function and maintain an airway without weeks of maxillomandibular fixation. Imaging and orthodontic preparation remain part of the overall plan.

Question 3Oral and Maxillofacial Surgery

A 24-year-old presents with a firm, well-defined radiolucency of the posterior mandible associated with an impacted third molar. Histology shows a lining of reduced enamel epithelium–like cells. What is the most likely diagnosis?

  1. Dentigerous cyst Correct answer.
  2. Central giant cell granuloma
  3. Ameloblastoma
  4. Odontogenic keratocyst

Explanation

A dentigerous cyst encloses the crown of an unerupted tooth and is lined by reduced enamel epithelium. It is the most common developmental odontogenic cyst and typically appears as a well-corticated radiolucency around an impacted crown.

Question 4Oral and Maxillofacial Surgery

Which local anesthetic property best explains why articaine provides effective pulpal anesthesia when buccal infiltration is used in the mandible?

  1. Low protein binding and rapid hepatic clearance
  2. Selective blockade of motor fibers
  3. Absence of a vasoconstrictor requirement
  4. High lipid solubility combined with a thiophene ring Correct answer.

Explanation

Articaine contains a thiophene ring that increases lipid solubility, enhancing diffusion through bone and nerve membranes. This supports its use as a buccal infiltration for mandibular pulpal anesthesia.

Question 5Oral and Maxillofacial Surgery

Which clinical finding most strongly suggests a diagnosis of temporomandibular joint dislocation rather than closed lock from disc displacement?

  1. Unilateral preauricular pain on palpation
  2. Clicking that occurs only on opening
  3. Limited opening of 25 mm with deviation
  4. Inability to close the mouth with the mandible fixed in an open position Correct answer.

Explanation

In true dislocation the condyle has moved anterior to the articular eminence, so the patient cannot close the mouth and the mandible is locked open. Closed lock from disc displacement presents as limited opening rather than inability to close.

Question 6Oral and Maxillofacial Surgery

A patient on warfarin with an INR of 3.2 requires extraction of a grossly carious mandibular molar. Which is the most appropriate perioperative approach?

  1. Stop warfarin five days preoperatively without bridging
  2. Give fresh frozen plasma in the dental chair before the extraction
  3. Double the warfarin dose postoperatively to compensate for bleeding
  4. Proceed with local measures and check INR on the day of surgery, coordinating with the physician Correct answer.

Explanation

For most minor oral surgery, an INR within the therapeutic range (generally up to about 3.5) permits extraction using local hemostatic measures. The INR should be checked close to the procedure and management coordinated with the prescribing physician.

Question 7Oral and Maxillofacial Surgery

Which radiographic feature most favors an odontogenic keratocyst over an ameloblastoma?

  1. Ground-glass appearance of the affected bone
  2. Soap-bubble multilocular appearance with root resorption
  3. Unilocular or multilocular lucency growing along the bone with minimal expansion Correct answer.
  4. Sunray spicules at the periphery

Explanation

Odontogenic keratocysts tend to grow anteroposteriorly within medullary bone with limited buccolingual expansion relative to their size. Ameloblastomas more often produce marked expansion and a soap-bubble pattern with root resorption.

Question 8Oral and Maxillofacial Surgery

After elevation of a maxillary third molar, a patient develops a defect in the buccal soft tissue with a small communication to the maxillary sinus. Which management step is most appropriate initially?

  1. Immediate Caldwell-Luc procedure
  2. Systemic corticosteroids alone
  3. Placement of a removable denture to seal the defect
  4. Primary closure of the oral communication and sinus precautions with follow-up Correct answer.

Explanation

Small oroantral communications often close spontaneously and are managed initially by primary soft tissue closure plus sinus precautions such as avoiding nose-blowing and sneezing with an open mouth. Larger or persistent defects may later require flap closure.

Question 9Oral and Maxillofacial Surgery

Which statement about Le Fort I osteotomy level is correct?

  1. It separates the zygoma from the frontal bone
  2. It involves removal of the condylar head
  3. It separates the maxilla above the apices of the teeth through the pyriform aperture and pterygomaxillary fissure Correct answer.
  4. It is a sagittal split of the mandibular ramus

Explanation

The Le Fort I osteotomy is a horizontal maxillary osteotomy passing above the dental apices from the pyriform rim through the lateral maxillary wall to the pterygomaxillary junction. It allows repositioning of the lower maxilla.

Question 10Oral and Maxillofacial Surgery

A patient with a history of bisphosphonate therapy for multiple myeloma presents with exposed necrotic bone of the mandible persisting for ten weeks. Which feature is required for the diagnosis of medication-related osteonecrosis of the jaw?

  1. Presence of a draining cutaneous fistula
  2. Elevated serum alkaline phosphatase
  3. Positive biopsy for metastatic plasma cells
  4. Exposed bone or bone probed through a fistula persisting beyond eight weeks with no history of radiation Correct answer.

Explanation

Medication-related osteonecrosis of the jaw is defined by exposed bone or bone probed through a fistula persisting for more than eight weeks in a patient with antiresorptive or antiangiogenic exposure and no history of head and neck radiation.

Question 11Oral and Maxillofacial Surgery

Which nerve is most at risk during a sagittal split ramus osteotomy, and what is the typical consequence of injury?

  1. Glossopharyngeal nerve; loss of taste on the posterior tongue
  2. Facial nerve; facial palsy
  3. Chorda tympani; loss of taste on the anterior tongue
  4. Inferior alveolar nerve; altered sensation of the lower lip and chin Correct answer.

Explanation

The inferior alveolar nerve runs through the mandibular ramus and body and is retracted during the sagittal split. Injury produces transient or persistent altered sensation of the lower lip, chin, and gingiva.

Question 12Oral and Maxillofacial Surgery

A child with a developing Class III malocclusion and maxillary hypoplasia is being evaluated for early treatment. Which intervention is most appropriate for orthopedic correction of the maxilla?

  1. Facemask protraction therapy Correct answer.
  2. Bilateral sagittal split osteotomy
  3. Mandibular setback with rigid fixation
  4. Condylectomy

Explanation

Facemask protraction applies anteriorly directed force to the maxilla and is used in growing patients to correct maxillary hypoplasia and Class III skeletal patterns. Orthognathic surgery is reserved for skeletal maturity.

Question 13Oral and Maxillofacial Surgery

Which clinical sign most reliably distinguishes a simple zygomatic arch fracture from a zygomaticomaxillary complex fracture?

  1. Diplopia on upward gaze
  2. Depression over the arch without infraorbital nerve deficit or malar flattening Correct answer.
  3. Subconjunctival hemorrhage
  4. Periorbital ecchymosis

Explanation

An isolated arch fracture produces a palpable depression over the arch with limited malar displacement. Zygomaticomaxillary complex fractures typically involve malar flattening, infraorbital nerve paresthesia, and orbital signs.

Question 14Oral and Maxillofacial Surgery

During extraction of a maxillary first molar, the crown fractures and a root is displaced. The patient later reports a foul taste and unilateral purulent nasal discharge. What is the most likely explanation?

  1. Injury to the greater palatine nerve
  2. Luxation of the tooth into the buccal space
  3. Fracture of the pterygoid plates
  4. Root displacement into the maxillary sinus Correct answer.

Explanation

A retained root pushed into the maxillary sinus can cause sinusitis with foul taste and unilateral purulent discharge. Radiographic localization and possible endoscopic retrieval are indicated.

Question 15Oral and Maxillofacial Surgery

Which is the most appropriate first-line management for a displaced mandibular condylar fracture with malocclusion but no airway compromise in an adult?

  1. Closed reduction with short-term maxillomandibular fixation and functional therapy Correct answer.
  2. Immediate open reduction and internal fixation in all cases
  3. Condylectomy
  4. Permanent maxillomandibular fixation for eight weeks

Explanation

Many displaced condylar fractures can be managed closed with a brief period of maxillomandibular fixation followed by early functional therapy to restore occlusion and motion. Open reduction is reserved for specific indications such as severe displacement or inability to restore occlusion.

Question 16Oral and Maxillofacial Surgery

A patient with a large mandibular ameloblastoma undergoes resection. Which reconstruction option is most appropriate for a segmental defect when immediate bone grafting is planned?

  1. Reconstruction plate with free fibula flap Correct answer.
  2. Simple soft tissue closure alone
  3. Observation with no reconstruction
  4. Placement of a removable partial denture immediately

Explanation

Segmental mandibular defects after tumor resection are commonly reconstructed with a vascularized free fibula flap and a reconstruction plate to restore continuity and allow dental rehabilitation. Soft tissue closure alone leaves a cosmetic and functional defect.

Question 17Oral and Maxillofacial Surgery

Which mechanism best explains the analgesic effect of a suprazygomatic maxillary nerve block for midface surgery?

  1. Blockade of the second division of the trigeminal nerve near the foramen rotundum Correct answer.
  2. Blockade of the hypoglossal nerve in the submandibular triangle
  3. Blockade of the cervical plexus at C2–C4
  4. Blockade of the facial nerve at the stylomastoid foramen

Explanation

The suprazygomatic approach deposits local anesthetic near the maxillary nerve as it exits the foramen rotundum, anesthetizing the V2 distribution. This provides analgesia for midface and maxillary procedures.

Question 18Oral and Maxillofacial Surgery

Which histological feature is characteristic of an ameloblastoma?

  1. Spindle cells with wavy nuclei in a myxoid background
  2. Multinucleated giant cells in a vascular stroma
  3. Reverse polarity of basal cells with stellate reticulum–like center Correct answer.
  4. Palisaded basal cells with parakeratinized corrugated surface

Explanation

Ameloblastoma shows islands of odontogenic epithelium with peripheral palisading and reverse polarity of basal cells, surrounding a stellate reticulum–like center. This pattern distinguishes it from other odontogenic lesions.

Question 19Oral and Maxillofacial Surgery

A patient reports a sudden inability to close the mouth after a long dental appointment, with the mandible locked open and pain in the preauricular region. Which maneuver is most appropriate for reduction?

  1. Perform immediate open joint surgery
  2. Apply downward and backward pressure on the mandible with the patient sedated and muscles relaxed Correct answer.
  3. Instruct the patient to open wider to reduce the dislocation
  4. Apply upward pressure on the chin to force closure

Explanation

Reduction of an anterior TMJ dislocation involves relaxing the muscles of mastication, then applying downward and posterior force on the mandible to seat the condyle back into the fossa. Sedation or local anesthesia may assist relaxation.

Question 20Oral and Maxillofacial Surgery

Which factor most increases the risk of infection after third molar surgery?

  1. Prolonged operating time and poor oral hygiene Correct answer.
  2. Use of a mouth prop
  3. Patient age under 20 years
  4. Use of local anesthesia with epinephrine

Explanation

Longer surgical time and poor preoperative oral hygiene increase bacterial load and tissue trauma, raising infection risk. Younger age and routine anesthetic techniques are not independent risk factors.

Question 21Oral and Maxillofacial Surgery

A patient with a suspected odontogenic infection involving the submandibular and sublingual spaces has difficulty swallowing and a raised floor of the mouth. Which is the most urgent concern?

  1. Chronic periodontitis progression
  2. Temporomandibular joint ankylosis
  3. Development of a salivary fistula
  4. Airway compromise from Ludwig angina Correct answer.

Explanation

Bilateral submandibular and sublingual space involvement with a raised floor of the mouth constitutes Ludwig angina, which threatens the airway. Urgent airway assessment, incision and drainage, and antibiotics are required.

Question 22Oral and Maxillofacial Surgery

Which imaging modality is most appropriate for evaluating the extent of a mandibular lesion and its relationship to the inferior alveolar canal before resection?

  1. Cone-beam computed tomography Correct answer.
  2. Bitewing radiographs
  3. Periapical radiographs of a single tooth
  4. Panoramic radiograph alone

Explanation

Cone-beam CT provides three-dimensional assessment of lesion extent, cortical integrity, and the course of the inferior alveolar canal, which is essential for surgical planning. Two-dimensional films lack this spatial detail.

Question 23Oral and Maxillofacial Surgery

Which best describes the role of the pterygomasseteric sling in the treatment of a mandibular angle fracture?

  1. It must be released to allow reduction and is repaired during fixation Correct answer.
  2. It should be left completely detached to prevent trismus
  3. It has no influence on fracture management
  4. It is removed to access the inferior alveolar nerve

Explanation

The pterygomasseteric sling often must be stripped to visualize and reduce an angle fracture, and it is repaired or allowed to reattach during fixation to restore muscle function and stability.

Question 24Oral and Maxillofacial Surgery

Which is a recognized advantage of distraction osteogenesis for mandibular reconstruction in a growing patient?

  1. It provides immediate full load-bearing strength
  2. It generates new bone gradually and can be combined with growth Correct answer.
  3. It requires no osteotomy
  4. It eliminates the need for any follow-up

Explanation

Distraction osteogenesis lengthens bone by gradual callus distraction, allowing adaptation to growth and generating native bone. It requires an osteotomy and careful follow-up, and early constructs are not fully load bearing.

Question 25Oral and Maxillofacial Surgery

A patient develops persistent trismus and limited mouth opening six months after a mandibular fracture treated with prolonged maxillomandibular fixation. Which is the most likely cause?

  1. Fibrous ankylosis or muscle fibrosis from prolonged immobilization Correct answer.
  2. Recurrent fracture of the condyle
  3. Dental caries
  4. Acute sinusitis

Explanation

Prolonged immobilization can lead to muscle fibrosis or fibrous ankylosis with restricted opening. Early mobilization and physiotherapy reduce this risk.

Question 26Oral and Maxillofacial Surgery

A 24-year-old patient presents with a firm, well-circumscribed swelling of the anterior maxilla. Radiographs show a unilocular radiolucency associated with the crown of an impacted canine. Histology reveals a lining of non-keratinized stratified squamous epithelium with focal mucous cells. Which is the most likely diagnosis?

  1. Radicular cyst
  2. Ameloblastoma
  3. Dentigerous cyst Correct answer.
  4. Odontogenic keratocyst

Explanation

A dentigerous cyst encloses the crown of an unerupted tooth and is lined by non-keratinized stratified squamous epithelium that may contain mucous cells. Odontogenic keratocysts have a parakeratinized lining with palisaded basal cells, radicular cysts are inflammatory and associated with a nonvital tooth, and ameloblastomas show odontogenic epithelium with reverse polarity and stellate reticulum.

Question 27Oral and Maxillofacial Surgery

During a Le Fort I osteotomy, which anatomical structure is most at risk when using a pterygomaxillary disjunction (osteotome) technique?

  1. The nasolacrimal duct at the medial orbital wall
  2. The greater palatine nerve in the greater palatine canal
  3. The infraorbital nerve at the infraorbital foramen
  4. The maxillary artery within the pterygopalatine fossa Correct answer.

Explanation

The pterygomaxillary disjunction is performed at the junction of the maxilla and pterygoid plates, where the maxillary artery lies in the pterygopalatine fossa. Injury can cause significant hemorrhage. The infraorbital nerve is at risk during anterior maxillary dissection, the greater palatine nerve during palatal surgery, and the nasolacrimal duct during medial orbital wall surgery.

Question 28Oral and Maxillofacial Surgery

Which local anesthetic property best explains why 0.5% bupivacaine provides longer postoperative analgesia than 2% lidocaine for third molar surgery?

  1. Higher lipid solubility and greater protein binding Correct answer.
  2. Higher concentration of the anesthetic solution
  3. Greater vasodilatory effect
  4. Lower pKa and faster onset of action

Explanation

Bupivacaine has high lipid solubility and strong protein binding, which prolongs its presence at the nerve membrane and extends analgesia. A lower pKa would speed onset, vasodilation would shorten duration, and concentration alone does not determine duration.

Question 29Oral and Maxillofacial Surgery

A 45-year-old patient with a history of smoking presents with a nonhealing ulcer on the lateral border of the tongue. Biopsy confirms squamous cell carcinoma. Which is the most important prognostic factor for survival?

  1. Tumor thickness
  2. Patient age
  3. Presence of cervical lymph node metastasis Correct answer.
  4. Tumor grade

Explanation

Cervical lymph node metastasis is the single most important prognostic factor in oral squamous cell carcinoma, significantly reducing survival. Tumor grade and thickness affect prognosis but are less influential, and age is not a primary prognostic factor.

Question 30Oral and Maxillofacial Surgery

A 32-year-old patient sustains a mandibular angle fracture. The fracture is minimally displaced and the patient has a stable occlusion. Which management strategy is most appropriate?

  1. Open reduction and internal fixation with two miniplates
  2. Closed reduction with maxillomandibular fixation for 4-6 weeks Correct answer.
  3. Observation with a soft diet only
  4. Open reduction and internal fixation with a single miniplate

Explanation

Minimally displaced mandibular angle fractures with a stable occlusion can be managed conservatively with closed reduction and maxillomandibular fixation. Open reduction is reserved for displaced or unstable fractures, and observation alone is insufficient because immobilization is needed for healing.

Question 31Oral and Maxillofacial Surgery

A 28-year-old patient presents with a discharging sinus near the angle of the mandible. Radiographs show a multilocular radiolucency with a 'soap bubble' appearance. Biopsy reveals a proliferation of odontogenic epithelium with reverse polarity and stellate reticulum. Which is the most appropriate initial management?

  1. Segmental mandibulectomy with immediate reconstruction
  2. Marsupialization alone
  3. Enucleation with peripheral ostectomy Correct answer.
  4. Radiation therapy

Explanation

The diagnosis is ameloblastoma, a locally aggressive odontogenic tumor. Enucleation with peripheral ostectomy is a common initial treatment for unicystic or small solid ameloblastomas, reducing recurrence. Marsupialization alone is insufficient, segmental resection is reserved for large or recurrent lesions, and radiation is not primary therapy.

Question 32Oral and Maxillofacial Surgery

A 60-year-old patient on long-term corticosteroid therapy develops a deep fascial space infection of the submandibular space. Which is the most urgent initial step in management?

  1. Start oral antibiotics and schedule outpatient follow-up
  2. Perform immediate surgical exploration without antibiotics
  3. Obtain a contrast-enhanced CT scan before any intervention
  4. Secure the airway and initiate intravenous antibiotics Correct answer.

Explanation

In deep fascial space infections, airway compromise is the most immediate threat, so securing the airway and starting broad-spectrum intravenous antibiotics are the first priorities. Imaging can follow once the patient is stabilized, oral antibiotics are inadequate for severe infection, and surgery should be paired with antibiotics, not performed without them.

Question 33Oral and Maxillofacial Surgery

A 22-year-old patient undergoes surgical removal of an impacted mandibular third molar. Two days later, the patient reports altered sensation on the ipsilateral lower lip and chin. Which nerve was most likely injured?

  1. Buccal nerve
  2. Inferior alveolar nerve Correct answer.
  3. Mylohyoid nerve
  4. Lingual nerve

Explanation

The inferior alveolar nerve provides sensation to the lower lip and chin, and it is at risk during third molar surgery due to its proximity to the roots. The lingual nerve affects the tongue, the mylohyoid nerve is motor to the mylohyoid muscle, and the buccal nerve supplies the cheek mucosa.

Question 34Oral and Maxillofacial Surgery

A 35-year-old patient presents with a firm, painless swelling in the parotid region. Fine-needle aspiration suggests a pleomorphic adenoma. Which treatment is most appropriate?

  1. Radical parotidectomy with facial nerve sacrifice
  2. Observation with annual MRI
  3. Enucleation of the tumor
  4. Superficial parotidectomy with facial nerve preservation Correct answer.

Explanation

Pleomorphic adenoma is the most common benign salivary gland tumor and is treated by superficial parotidectomy with facial nerve preservation to minimize recurrence. Enucleation alone has a high recurrence rate, radical surgery with nerve sacrifice is overtreatment for a benign lesion, and observation risks continued growth and malignant transformation.

Question 35Oral and Maxillofacial Surgery

A 50-year-old patient with a history of radiotherapy to the head and neck undergoes extraction of a mandibular molar. Six months later, the patient presents with exposed bone and no signs of healing. Which is the most likely diagnosis?

  1. Osteoradionecrosis Correct answer.
  2. Fibrous dysplasia
  3. Medication-related osteonecrosis of the jaw
  4. Osteomyelitis

Explanation

Osteoradionecrosis occurs after radiotherapy, often triggered by extraction, and presents with exposed nonhealing bone. Medication-related osteonecrosis is associated with antiresorptive or antiangiogenic drugs, osteomyelitis typically shows signs of infection, and fibrous dysplasia is a developmental disorder.

Question 36Oral and Maxillofacial Surgery

A 16-year-old patient with a Class II malocclusion and mandibular retrognathia is planned for orthognathic surgery. Which preoperative assessment is most critical for determining the need for a two-jaw procedure?

  1. Evaluation of the airway
  2. Cephalometric analysis of the maxillomandibular relationship Correct answer.
  3. Assessment of temporomandibular joint function
  4. Dental model analysis

Explanation

Cephalometric analysis is essential for evaluating the maxillomandibular relationship and deciding whether single-jaw or two-jaw surgery is needed. Airway, dental models, and TMJ function are important but do not primarily determine the need for a two-jaw procedure.

Question 37Oral and Maxillofacial Surgery

A 70-year-old patient with a mandibular fracture is being considered for open reduction and internal fixation. Which factor most increases the risk of hardware failure?

  1. History of smoking
  2. Poor bone quality due to osteoporosis Correct answer.
  3. Early mobilization
  4. Use of a single miniplate

Explanation

Poor bone quality, such as from osteoporosis, reduces screw purchase and increases the risk of hardware failure. A single miniplate is often adequate, smoking impairs healing but is not the strongest predictor of hardware failure, and early mobilization is generally encouraged.

Question 38Oral and Maxillofacial Surgery

A 55-year-old patient presents with a painless, slowly enlarging swelling of the anterior mandible. Radiographs show a well-defined multilocular radiolucency. Biopsy reveals a proliferation of spindle cells with woven bone formation. Which is the most likely diagnosis?

  1. Ameloblastoma
  2. Fibrous dysplasia Correct answer.
  3. Osteosarcoma
  4. Ossifying fibroma

Explanation

Fibrous dysplasia presents as a painless swelling with a 'ground-glass' radiolucency and histologically shows spindle cells with woven bone trabeculae lacking osteoblastic rimming. Ossifying fibroma typically shows osteoblastic rimming, osteosarcoma is malignant with atypical cells, and ameloblastoma lacks bone formation.

Question 39Oral and Maxillofacial Surgery

During a sagittal split ramus osteotomy, which maneuver best minimizes injury to the inferior alveolar nerve?

  1. Aggressive medial retraction of the nerve
  2. Performing the osteotomy without irrigation
  3. Use of a reciprocating saw for the osteotomy
  4. Adequate visualization and careful separation of the nerve from the proximal segment Correct answer.

Explanation

The inferior alveolar nerve is at risk during sagittal split osteotomy, and careful visualization and separation from the proximal segment help prevent injury. Aggressive retraction can cause neurapraxia, a reciprocating saw may increase risk, and lack of irrigation leads to thermal damage.

Question 40Oral and Maxillofacial Surgery

A 40-year-old patient with a history of bisphosphonate therapy for breast cancer presents with exposed bone in the mandible. Which management strategy is most appropriate for stage 2 medication-related osteonecrosis of the jaw?

  1. Antibiotic therapy and superficial debridement Correct answer.
  2. Hyperbaric oxygen therapy alone
  3. Observation only
  4. Immediate segmental resection

Explanation

Stage 2 MRONJ is characterized by exposed bone with infection, and management includes antibiotics and superficial debridement. Segmental resection is reserved for advanced or refractory cases, hyperbaric oxygen alone is not standard, and observation is inadequate for symptomatic infection.

Question 41Anesthesia and Pain Management

A patient scheduled for oral surgery reports a history of malignant hyperthermia in a sibling. Which volatile agent should be avoided intraoperatively?

  1. Propofol
  2. Remifentanil
  3. Sevoflurane Correct answer.
  4. Midazolam

Explanation

Volatile halogenated anesthetics such as sevoflurane are classic triggers of malignant hyperthermia and must be avoided in susceptible patients. Total intravenous anesthesia with propofol, an opioid, and a non-depolarizing relaxant is a standard safe approach.

Question 42Anesthesia and Pain Management

Which drug is the first-line specific treatment for an acute malignant hyperthermia crisis?

  1. Naloxone
  2. Atropine
  3. Dantrolene Correct answer.
  4. Sodium bicarbonate

Explanation

Dantrolene inhibits ryanodine receptor-mediated calcium release from the sarcoplasmic reticulum and is the only specific antidote for malignant hyperthermia. Supportive measures such as cooling, hyperventilation, and treating hyperkalemia are given alongside it.

Question 43Anesthesia and Pain Management

During administration of a local anesthetic, a patient develops perioral numbness, tinnitus, and a metallic taste. These findings most suggest which process?

  1. Local anesthetic systemic toxicity Correct answer.
  2. Anaphylaxis to the preservative
  3. Vasovagal syncope
  4. Epinephrine-induced hypertension

Explanation

Perioral numbness, tinnitus, and a metallic taste are classic early excitatory symptoms of local anesthetic systemic toxicity before central nervous system depression and cardiovascular collapse develop. Management includes stopping injection, airway support, and lipid emulsion therapy for severe cases.

Question 44Anesthesia and Pain Management

Which agent is the recommended rescue therapy for severe local anesthetic systemic toxicity with cardiovascular collapse?

  1. Intravenous flumazenil
  2. Intravenous calcium chloride
  3. Intravenous ketamine
  4. Intravenous lipid emulsion Correct answer.

Explanation

Intravenous lipid emulsion is the specific rescue therapy for severe local anesthetic systemic toxicity, acting as a lipid sink to sequester the anesthetic. It is given with standard resuscitation, airway management, and avoidance of vasopressin and large doses of epinephrine.

Question 45Anesthesia and Pain Management

Which analgesic is generally avoided in a patient with a history of opioid use disorder who requires postoperative pain control without opioid therapy?

  1. Acetaminophen
  2. Tramadol Correct answer.
  3. Celecoxib
  4. Ibuprofen

Explanation

Tramadol is an opioid agonist and can perpetuate dependence or precipitate withdrawal in patients maintained on opioid antagonists. Non-opioid options such as NSAIDs and acetaminophen are preferred in opioid-avoidant plans.

Question 46Anesthesia and Pain Management

A patient receiving chronic opioid therapy for cancer pain reports new severe pain and requests an increase in dose. What is the most appropriate initial step?

  1. Assess for a new cause of pain and review adherence Correct answer.
  2. Refer for opioid detoxification
  3. Immediately double the long-acting opioid dose
  4. Discontinue the opioid and start an NSAID

Explanation

A new escalation of pain in a patient on chronic opioids warrants evaluation for disease progression, new pathology, or nonadherence before adjusting therapy. Reassessment guides whether to add breakthrough dosing, rotate opioids, or add adjuvants.

Question 47Anesthesia and Pain Management

Which monitoring finding is the earliest reliable indicator of hypoxemia during procedural sedation?

  1. Rise in blood pressure
  2. Fall in end-tidal carbon dioxide
  3. Pulse oximetry desaturation Correct answer.
  4. Increase in heart rate

Explanation

Pulse oximetry desaturation reflects falling arterial oxygen saturation and is the standard early warning of hypoxemia during sedation. Capnography can detect hypoventilation even earlier, but oxygen desaturation is the classic monitored sign.

Question 48Anesthesia and Pain Management

A patient on warfarin requires an urgent dental extraction and has an INR of 3.8. Which action is most appropriate before the procedure?

  1. Double the warfarin dose postoperatively
  2. Give fresh frozen plasma in the dental chair
  3. Consult the prescriber about reversing or holding warfarin Correct answer.
  4. Proceed without modification

Explanation

An INR of 3.8 exceeds the typical therapeutic range and raises bleeding risk for an invasive procedure, so the anticoagulation prescriber should be consulted about holding or reversing therapy. Local hemostatic measures are also planned.

Question 49Anesthesia and Pain Management

Which drug interaction most increases the risk of respiratory depression when an opioid is co-administered?

  1. Benzodiazepine Correct answer.
  2. Amoxicillin
  3. Acetaminophen
  4. Metformin

Explanation

Benzodiazepines and opioids act synergistically on central nervous system depression, markedly increasing the risk of sedation and respiratory depression. This combination warrants lower doses and closer monitoring.

Question 50Anesthesia and Pain Management

A patient with severe hepatic impairment requires analgesia. Which opioid is most affected by reduced hepatic clearance and requires the greatest caution?

  1. Sufentanil
  2. Fentanyl
  3. Morphine Correct answer.
  4. Remifentanil

Explanation

Morphine undergoes extensive hepatic glucuronidation, and its active metabolites accumulate in hepatic impairment, increasing sedation risk. Fentanyl and remifentanil are less dependent on hepatic clearance and are often preferred in severe liver disease.