Epiglottitis — MCQs
A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
What is the most appropriate antibiotic choice for a 4-year-old unvaccinated child with epiglottitis?
A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
Best management for an inhaled foreign body in an infant is?
True about carcinoma of the larynx?
Which of the following is NOT used in the treatment of Juvenile Laryngeal Papillomatosis?
What is the standard treatment for T1N0M0 laryngeal cancer?
Dead space is reduced in tracheostomy by what percentage?
For foreign bodies retained in the larynx causing choking, what is the first-line management?
Which of the following lasers is most commonly used in laryngeal surgery?
Epiglottitis Indian Medical PG Practice Questions and MCQs
Question 1: A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
- A. FB in larynx
- B. Angioneurotic edema (Correct Answer)
- C. Parapharyngeal abscess
- D. FB bronchus
Explanation: Andioneurotic edema - The combination of **tongue swelling**, **neck swelling**, **stridor**, and **hoarseness of voice** following peanut ingestion is highly suggestive of **angioneurotic edema**, a severe allergic reaction that can lead to airway obstruction [1]. - This is a life-threatening condition requiring immediate medical intervention, often associated with generalized **anaphylaxis** when triggered by allergens [2]. *FB in larynx* - While a **foreign body (FB) in the larynx** can cause stridor and hoarseness, the widespread swelling of the tongue and neck points away from a localized laryngeal obstruction [3]. - A laryngeal FB would typically be associated with a more sudden onset of choking and coughing, not diffuse edema [3]. *Parapharyngeal abscess* - A **parapharyngeal abscess** would typically present with **fever**, **severe throat pain**, and **trismus** (difficulty opening the mouth), which are not mentioned in this scenario. - The acute, rapid onset of symptoms after peanut consumption is inconsistent with the slower progression of an abscess. *FB bronchus* - A **foreign body in the bronchus** would primarily cause **coughing**, **wheezing**, and possibly **respiratory distress**, often unilateral, rather than severe global swelling of the tongue and neck. - Inspiratory stridor and hoarseness are more indicative of upper airway involvement than bronchial obstruction.
Question 2: What is the most appropriate antibiotic choice for a 4-year-old unvaccinated child with epiglottitis?
- A. Administering a vaccine
- B. Doxycycline for 4 days
- C. Immediate airway assessment and management
- D. Ceftriaxone or cefotaxime (Correct Answer)
Explanation: ***Ceftriaxone or cefotaxime*** - **Third-generation cephalosporins** are the **first-line antibiotics** for epiglottitis in children - Provide excellent coverage against ***Haemophilus influenzae* type b (Hib)**, the most common causative organism in unvaccinated children - Effective against **both beta-lactamase producing and non-producing strains**, addressing the widespread ampicillin resistance (20-40%) - **Ceftriaxone** (50-100 mg/kg/day) or **cefotaxime** (150-200 mg/kg/day divided) are standard of care - Treatment duration is typically **7-10 days** *Immediate airway assessment and management* - While this is the **most critical priority** in epiglottitis management (life-threatening airway obstruction risk), the question specifically asks for **antibiotic choice** - Airway management is a procedural intervention, not antimicrobial therapy - In clinical practice, airway assessment comes first, but this doesn't answer the question asked *Administering a vaccine* - **Hib vaccine** is a **preventive measure**, not a treatment for active infection - Vaccination during acute epiglottitis has no therapeutic benefit - The vaccine prevents future disease but does not treat current infection *Doxycycline for 4 days* - **Not first-line therapy** for epiglottitis in any age group - **Contraindicated in children under 8 years** due to risk of permanent **tooth discoloration** and enamel hypoplasia - Poor coverage against *H. influenzae* type b - Tetracyclines are not recommended for typical bacterial causes of epiglottitis
Question 3: A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
- A. Acute Laryngotracheobronchitis (Correct Answer)
- B. Acute Bacterial Tracheitis
- C. Acute Epiglottitis
- D. Foreign Body aspiration
Explanation: ***Acute Laryngotracheobronchitis*** - The combination of **low-grade fever** and **stridor** in a 2-year-old child strongly suggests **croup**, which is medically known as acute laryngotracheobronchitis. - Croup is characterized by **inflammation** of the larynx, trachea, and bronchi, often presenting with a **barking cough** and inspiratory stridor. The X-ray image would show the characteristic **steeple sign**. *Acute Bacterial Tracheitis* - This is a more severe bacterial infection that can present with stridor but typically shows **higher fever**, **toxic appearance**, and rapid clinical deterioration. - Unlike croup, bacterial tracheitis patients appear **more ill** and may have **purulent secretions** requiring more aggressive management. *Acute Epiglottitis* - A serious condition characterized by **rapid onset of high fever**, **dysphagia**, drooling, and a **"tripod" position**, which are not indicated by the given symptoms. - The stridor in epiglottitis is typically quieter and may indicate more severe airway obstruction compared to the characteristic stridor of croup. *Foreign Body aspiration* - While foreign body aspiration can cause stridor, it is typically an **acute event** with a sudden onset of choking, coughing, and respiratory distress. - There is no mention of a choking episode or sudden onset, and a low-grade fever is less typical for an uncomplicated foreign body aspiration.
Question 4: Best management for an inhaled foreign body in an infant is?
- A. IPPV
- B. Tracheostomy
- C. Corticosteroids
- D. Bronchoscopy (Correct Answer)
Explanation: ***Bronchoscopy*** - **Bronchoscopy** is the definitive and most effective procedure for both diagnosing and removing an inhaled foreign body in an infant. - It allows direct visualization of the airways and the precise retrieval of the foreign object, preventing complications like **atelectasis** or **pneumonia**. *Tracheostomy* - **Tracheostomy** is an emergency procedure to create a surgical airway, usually reserved for severe upper airway obstruction that cannot be managed by less invasive means. - It is not the primary line of treatment for removing an inhaled foreign body, which is typically found further down in the **bronchial tree**. *Corticosteroids* - **Corticosteroids** are used to reduce inflammation and edema in the airways, but they do not remove the foreign body itself. - While they might be used as an adjunct in managing airway inflammation after removal, they are not the definitive treatment for the foreign body. *IPPV* - **Intermittent Positive Pressure Ventilation (IPPV)** is a method of respiratory support used for patients with respiratory failure. - It does not address the physical obstruction caused by an inhaled foreign body and may even push the object further into the airway or cause **pneumothorax**.
Question 5: True about carcinoma of the larynx?
- A. Glottis is the most common site. (Correct Answer)
- B. It rarely presents with metastasis.
- C. Adenocarcinoma is the commonest type.
- D. It responds to chemotherapy very well.
Explanation: ### Explanation **Correct Option: A. Glottis is the most common site.** In the Indian subcontinent and globally, the **glottis (vocal cords)** is the most common site for laryngeal carcinoma (approx. 60-65%), followed by the supraglottis (30-35%) and the subglottis (1-5%). Glottic tumors often present early due to hoarseness of voice, which occurs even with tiny lesions. **Analysis of Incorrect Options:** * **B. It rarely presents with metastasis:** This is incorrect. While glottic cancers have a low rate of metastasis due to sparse lymphatic drainage, **supraglottic cancers** have a rich lymphatic network and frequently present with early cervical lymph node metastasis (often bilateral). * **C. Adenocarcinoma is the commonest type:** Incorrect. Over 95% of laryngeal cancers are **Squamous Cell Carcinomas (SCC)**. Adenocarcinoma is rare and usually arises from minor salivary glands. * **D. It responds to chemotherapy very well:** Incorrect. The primary treatment modalities for laryngeal cancer are **Surgery and Radiotherapy**. Chemotherapy is typically used as an adjuvant or for "organ preservation" protocols (e.g., Cisplatin) rather than being the definitive treatment of choice. **High-Yield Clinical Pearls for NEET-PG:** * **Best Prognosis:** Glottic cancer (due to early symptoms and poor lymphatics). * **Worst Prognosis:** Subglottic cancer (presents late and has a high risk of paratracheal node involvement). * **Most Common Site of Distant Metastasis:** Lungs. * **Staging:** T1a involves one vocal cord; T1b involves both cords. T3 implies vocal cord fixation. * **Risk Factors:** Smoking (strongest association) and Alcohol (synergistic effect).
Question 6: Which of the following is NOT used in the treatment of Juvenile Laryngeal Papillomatosis?
- A. Interferon alpha (INF α)
- B. Interferon beta (INF β) (Correct Answer)
- C. Bevacizumab
- D. Cedofovir
Explanation: **Explanation:** Juvenile Laryngeal Papillomatosis (JLP), caused by **HPV types 6 and 11**, is characterized by recurrent benign epithelial tumors. The primary treatment is surgical debulking (CO2 laser or microdebrider), but adjuvant medical therapy is indicated when the disease is aggressive (requiring >4 surgeries per year). **Why Option B is Correct:** **Interferon beta (INF β)** is not a standard treatment for JLP. While Interferons have antiviral and antiproliferative properties, clinical evidence and established protocols specifically utilize **Interferon alpha (INF α)**. INF β does not have a proven role in the management of this condition. **Analysis of Incorrect Options:** * **Interferon alpha (INF α):** Historically the first-line adjuvant therapy. It slows the rate of recurrence by inducing antiviral states in cells, though it rarely provides a permanent cure and has significant side effects (flu-like symptoms, growth retardation). * **Cidofovir:** A potent antiviral (cytosine nucleotide analog) administered via **intralesional injection**. It is currently one of the most commonly used adjuvant agents for recalcitrant cases. * **Bevacizumab:** An anti-VEGF monoclonal antibody. It is a newer, highly effective treatment (administered systemically or intralesionally) that inhibits the angiogenesis required for papilloma growth. **High-Yield Clinical Pearls for NEET-PG:** * **Most common benign tumor** of the larynx in children. * **Triad of symptoms:** Hoarseness (most common), stridor, and respiratory distress. * **Diagnosis:** Direct laryngoscopy shows "cauliflower-like" masses. * **Gold Standard Adjuvant:** Cidofovir (Intralesional). * **Newer Trend:** Bevacizumab is increasingly preferred for severe cases. * **Note:** Tracheostomy should be avoided as it may lead to "stomal seeding" of the papilloma.
Question 7: What is the standard treatment for T1N0M0 laryngeal cancer?
- A. Radiotherapy (Correct Answer)
- B. Total laryngectomy
- C. Laser therapy
- D. Microlaryngoscopic surgery
Explanation: **Explanation:** The management of early-stage laryngeal cancer (T1N0M0) focuses on **organ preservation** and maintaining voice quality. For T1 lesions, both **Radiotherapy (RT)** and **Endoscopic CO2 Laser Excision** are considered standard treatments, as they offer similar local control and survival rates (approx. 90-95%). **Why Radiotherapy is the Correct Answer:** In the context of standard examinations like NEET-PG, **Radiotherapy** is traditionally favored as the primary answer for T1 glottic lesions because it provides an excellent functional outcome with a superior voice quality compared to surgery. It treats the entire larynx, addressing potential multicentricity of the disease without the need for surgical margins. **Analysis of Incorrect Options:** * **B. Total Laryngectomy:** This is a radical procedure reserved for advanced stages (T3 or T4) where the larynx is non-functional or there is extensive cartilage destruction. It is never the first-line treatment for T1 disease. * **C. Laser Therapy:** While highly effective and increasingly popular (Transoral Laser Microsurgery - TLM), it is often considered an alternative to RT. In many textbooks, RT remains the "classic" gold standard for voice preservation in T1. * **D. Microlaryngoscopic Surgery:** While used for biopsy or very superficial "stripping," it is generally insufficient as a standalone curative treatment for invasive T1 cancer unless performed via CO2 laser (TLM). **Clinical Pearls for NEET-PG:** * **T1a:** Involves one vocal cord; **T1b:** Involves both vocal cords. * **Voice Quality:** RT generally offers a better "smooth" voice, whereas Laser surgery may result in a "breathy" or "rough" voice due to tissue loss. * **Salvage:** If RT fails, surgery (Partial or Total Laryngectomy) can still be performed. * **Treatment of Choice for T3/T4:** Concurrent Chemoradiotherapy (for organ preservation) or Total Laryngectomy.
Question 8: Dead space is reduced in tracheostomy by what percentage?
- A. 5-10%
- B. 15-20%
- C. 20-30%
- D. 30-50% (Correct Answer)
Explanation: ### Explanation **Concept:** Tracheostomy reduces the **anatomical dead space**—the volume of the conducting airways where no gas exchange occurs (nose, pharynx, larynx, and upper trachea). By creating an opening in the neck and bypassing the upper respiratory tract, the inspired air travels a significantly shorter distance to reach the alveoli. **Why 30-50% is Correct:** In a healthy adult, the anatomical dead space is approximately **150 ml**. A tracheostomy bypasses the entire upper airway, which accounts for nearly half of this volume. Standard medical literature and ENT textbooks (like Dhingra) state that a tracheostomy reduces this dead space by **30% to 50%**. This reduction is clinically significant as it improves alveolar ventilation and reduces the work of breathing, especially in patients with respiratory failure or chronic lung disease. **Analysis of Incorrect Options:** * **A (5-10%) & B (15-20%):** These values are too low. Bypassing the entire oral/nasal cavity and the larynx removes a much larger proportion of the conducting pathway than these percentages suggest. * **C (20-30%):** While closer, this underestimates the contribution of the upper airway to the total dead space volume. **High-Yield Clinical Pearls for NEET-PG:** * **Physiological Effects of Tracheostomy:** 1. **Reduced Dead Space:** (30-50%) Improves ventilation efficiency. 2. **Reduced Resistance:** Decreases the work of breathing. 3. **Bypasses Laryngeal Protection:** Increases the risk of aspiration. 4. **Loss of Humidification:** Leads to crusting and ciliary dysfunction (requires external humidification). * **Dead Space Calculation:** Anatomical dead space is roughly **2 ml/kg** of body weight. * **Key Indication:** Tracheostomy is indicated when "prolonged intubation" is expected (usually >7-14 days) to prevent subglottic stenosis.
Question 9: For foreign bodies retained in the larynx causing choking, what is the first-line management?
- A. Airway intubation
- B. Heimlich maneuver (Correct Answer)
- C. Heimlich valve
- D. Tracheostomy
Explanation: **Explanation:** The **Heimlich maneuver** (subdiaphragmatic abdominal thrusts) is the gold-standard first-line emergency management for an upper airway obstruction caused by a foreign body. The physiological principle is to create an **"artificial cough"** by elevating the diaphragm, which increases intrathoracic pressure and forces air out of the lungs to expel the obstructing object. **Analysis of Options:** * **Heimlich Maneuver (Correct):** It is non-invasive, requires no equipment, and is the immediate step for a conscious choking victim. * **Airway Intubation (Incorrect):** Intubation is technically difficult or impossible if a foreign body is physically blocking the laryngeal inlet. Attempting it may push the object further down. * **Heimlich Valve (Incorrect):** This is a one-way valve used in the management of a pneumothorax to allow air to exit the pleural space; it has no role in airway obstruction. * **Tracheostomy (Incorrect):** While it provides a definitive surgical airway, it is time-consuming and considered only if non-invasive maneuvers (Heimlich) and basic life support (cricothyroidotomy) fail. **High-Yield Clinical Pearls for NEET-PG:** * **In Infants (<1 year):** Abdominal thrusts are contraindicated due to the risk of liver injury. Use **5 back blows and 5 chest thrusts** instead. * **In Pregnant/Obese Patients:** Use **chest thrusts** (lower sternum) instead of abdominal thrusts. * **Unconscious Patient:** If the patient becomes unresponsive, start **CPR** immediately. The chest compressions serve the dual purpose of circulating blood and providing pressure to dislodge the foreign body. * **Gold Standard Investigation:** For a stable patient with suspected foreign body inhalation, **Rigid Bronchoscopy** is the investigation and treatment of choice.
Question 10: Which of the following lasers is most commonly used in laryngeal surgery?
- A. CO2 laser (Correct Answer)
- B. Nd:YAG laser
- C. Argon laser
- D. KTP laser
Explanation: **Explanation:** The **CO2 laser (Carbon Dioxide laser)** is the "gold standard" and most commonly used laser in laryngeal surgery. Its wavelength (10,600 nm) is highly absorbed by water, which constitutes the majority of soft tissue. This results in **excellent precision** with minimal peripheral thermal damage (shallow penetration depth of 0.1 mm). In the larynx, where preserving delicate vocal cord architecture is vital, the CO2 laser allows for "what you see is what you get" surgery, providing a bloodless field and rapid healing. **Analysis of Incorrect Options:** * **Nd:YAG laser:** This has deep tissue penetration (up to 4–5 mm) and excellent hemostatic properties. However, its lack of precision and risk of significant collateral thermal injury make it unsuitable for delicate laryngeal work; it is more commonly used for debulking large tracheobronchial tumors. * **Argon laser:** This is absorbed by hemoglobin and melanin. It is primarily used in otology (e.g., stapedotomy) or ophthalmology, but lacks the versatility required for major laryngeal resections. * **KTP laser (Potassium Titanyl Phosphate):** While used in the larynx for vascular lesions (like laryngeal papillomas or ectasias) because it is selectively absorbed by hemoglobin, it is not the *most common* or primary tool for general laryngeal surgery compared to the CO2 laser. **Clinical Pearls for NEET-PG:** * **Laser Safety:** The most dreaded complication of laryngeal laser surgery is an **airway fire**. To prevent this, surgeons use laser-resistant endotracheal tubes and fill the cuff with saline tinted with **methylene blue** (to signal a cuff breach). * **Mode of delivery:** CO2 lasers are typically delivered via a micromanipulator attached to an operating microscope. * **Key Indication:** CO2 laser is the treatment of choice for **T1 glottic cancer** and **Laryngeal Papillomatosis**.
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