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?
Vocal cord palsy is not associated with which of the following?
What is the gold standard test for the diagnosis of laryngopharyngeal reflux?
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: Vocal cord palsy is not associated with which of the following?
- A. Vertebral secondaries (Correct Answer)
- B. Left atrial enlargement
- C. Bronchogenic carcinoma
- D. Secondaries in mediastinum
Explanation: ### Explanation The correct answer is **A. Vertebral secondaries**. The Recurrent Laryngeal Nerve (RLN) has a long, circuitous course, especially on the left side. Vocal cord palsy occurs when there is compression or infiltration of the RLN along its path from the skull base to the thorax. **Why Vertebral Secondaries is the correct answer:** Vertebral secondaries (metastasis to the spinal column) typically involve the bony structures of the spine. The RLN runs in the **tracheoesophageal groove** in the neck and within the **mediastinum** in the thorax. It does not come into direct anatomical contact with the vertebral bodies. Therefore, unless there is massive paraspinal extension involving the mediastinum or neck soft tissues, vertebral secondaries do not cause vocal cord palsy. **Analysis of Incorrect Options:** * **Left Atrial Enlargement:** Causes **Ortner’s Syndrome** (Cardiovocal syndrome). The enlarged left atrium pushes the left pulmonary artery upwards, compressing the left RLN against the aortic arch. * **Bronchogenic Carcinoma:** This is the most common malignant cause of left RLN palsy. The nerve is involved either by the primary tumor at the lung apex (Pancoast tumor) or by hilar lymphadenopathy. * **Secondaries in Mediastinum:** Mediastinal lymph nodes (paratracheal or subcarinal) are a frequent site for metastasis. Enlargement of these nodes directly compresses the RLN as it loops around the aorta (left) or subclavian artery (right). **High-Yield Clinical Pearls for NEET-PG:** 1. **Left vs. Right:** Left RLN palsy is more common than right because of its longer intrathoracic course (looping around the Arch of Aorta). 2. **Semon’s Law:** In progressive lesions, abductor fibers are injured first; the cord first moves to the midline (adducted position). 3. **Most common cause:** Overall, the most common cause of unilateral vocal cord palsy is **idiopathic**, followed by **surgical trauma** (Thyroidectomy). 4. **Ortner’s Syndrome:** Classically associated with Mitral Stenosis leading to Left Atrial Enlargement.
Question 10: What is the gold standard test for the diagnosis of laryngopharyngeal reflux?
- A. 24-hour double probe pH monitoring (Correct Answer)
- B. Flexible endoscope
- C. Barium swallow
- D. Laryngoscopy
Explanation: ### Explanation **1. Why Option A is Correct:** Laryngopharyngeal Reflux (LPR) occurs when gastric contents travel retrograde past the upper esophageal sphincter into the pharynx and larynx. The **24-hour double probe pH monitoring** is the **gold standard** for diagnosis. It utilizes two sensors: one placed in the distal esophagus (to detect GERD) and a second "proximal" probe placed in the hypopharynx (above the upper esophageal sphincter). This allows for the definitive detection of acid exposure in the laryngeal area, which is more sensitive to acid damage than the esophagus. **2. Why Other Options are Incorrect:** * **B. Flexible Endoscope / D. Laryngoscopy:** While these are essential for visualizing signs of LPR (such as posterior commissure hypertrophy, "pseudosulcus vocalis," or laryngeal edema), they are subjective. Many patients with LPR have a normal-looking larynx, and many healthy individuals show some laryngeal redness, making these tests non-confirmatory. * **C. Barium Swallow:** This is useful for detecting structural abnormalities (like strictures or webs) or significant motility disorders, but it lacks the sensitivity to detect the transient, intermittent reflux episodes characteristic of LPR. **3. Clinical Pearls for NEET-PG:** * **Reflux Finding Score (RFS):** A clinical tool used during laryngoscopy to quantify the severity of LPR findings (Score >7 is suggestive). * **Reflux Symptom Index (RSI):** A self-administered questionnaire for patients (Score >13 is suggestive). * **Key Symptom:** Unlike GERD, where "heartburn" is common, the most common symptom of LPR is **globus pharyngeus** (sensation of a lump in the throat) and chronic throat clearing. * **Treatment:** LPR requires more aggressive and longer treatment than GERD, typically involving **twice-daily (BID) Proton Pump Inhibitors (PPIs)** for 3–6 months.
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