Pediatric Otolaryngology — MCQs

A 5-year-old girl is admitted to the hospital with an upper respiratory tract infection. During physical examination her sense of hearing appears to be poor. Her right ear is painful, and upon otoscopic examination a golden-brown fluid can be observed through the tympanic membrane. Which is the most likely direct route for the spread of an infection from the upper respiratory tract to the middle ear cavity?

Q40Medium

A 4-year-old male presents with recurrent upper respiratory tract infections, difficulty breathing, high arched palate, failure to grow, and impaired hearing. What is the most appropriate management?

Pediatric Otolaryngology Indian Medical PG Practice Questions and MCQs

Question 31: What is the most common cause of stridor in infants and young children?

A. Abductor vocal cord palsy
B. Croup
C. Laryngomalacia (Correct Answer)
D. Epiglottitis

Explanation: **Explanation:** **Laryngomalacia** is the most common cause of congenital stridor and the most frequent congenital anomaly of the larynx. It is characterized by an inward collapse of the supraglottic structures (epiglottis, aryepiglottic folds, and arytenoids) during inspiration due to excessive tissue laxity. This results in a classic **inspiratory stridor** that typically appears within the first two weeks of life, worsens with crying or feeding, and improves when the infant is placed in a prone position. **Analysis of Incorrect Options:** * **Abductor Vocal Cord Palsy:** This is the second most common cause of congenital stridor. It often presents with biphasic stridor and may be associated with neurological conditions like Arnold-Chiari malformation. * **Croup (Laryngotracheobronchitis):** While it is the most common cause of *acute* infectious stridor in children (6 months to 3 years), it is not the most common cause of stridor overall in the neonatal/infant period. It presents with a characteristic "barking cough." * **Epiglottitis:** This is an acute, life-threatening bacterial infection (usually *H. influenzae* type B). It presents with high fever, drooling, and a "thumb sign" on X-ray, but its incidence has significantly decreased due to vaccination. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Gold standard is **Flexible Fiberoptic Laryngoscopy**, which shows an omega-shaped (Ω) epiglottis and redundant arytenoid mucosa. * **Management:** Most cases (90%) are self-limiting and resolve by 18–24 months. Severe cases (causing failure to thrive or cor pulmonale) require **Supraglottoplasty**. * **Key Association:** Frequently associated with Gastroesophageal Reflux Disease (GERD).

Question 32: A retroauricular incision in children less than 2 years of age may cause damage to which cranial nerve?

A. Cranial Nerve VIII
B. Cranial Nerve VII
C. Cranial Nerve VI (Correct Answer)
D. Cranial Nerve V

Explanation: **Explanation:** The correct answer is **Cranial Nerve VII (Facial Nerve)**. *(Note: There appears to be a typographical error in the provided key; while the prompt indicates Option C as correct, the anatomical and clinical fact is that the **Facial Nerve (CN VII)** is the structure at risk.)* **Why Cranial Nerve VII is at risk:** In infants and children under 2 years of age, the **mastoid process is not yet developed**. In adults, the mastoid process acts as a bony shield for the facial nerve as it exits the stylomastoid foramen. In young children, the stylomastoid foramen is located more superficially and laterally on the skull base. Consequently, a standard retroauricular incision—if carried too far inferiorly or anteriorly—can directly transect the facial nerve trunk as it emerges near the surface. **Analysis of Incorrect Options:** * **Cranial Nerve VIII (Vestibulocochlear):** This nerve is located deep within the internal auditory canal and the bony labyrinth. It is not at risk during a superficial retroauricular skin incision. * **Cranial Nerve VI (Abducens):** This nerve controls the lateral rectus muscle of the eye and has an intracranial course. It is anatomically distant from the post-auricular surgical site. * **Cranial Nerve V (Trigeminal):** This nerve provides facial sensation and mastication motor function. Its branches are located anterior to the ear and deep within the skull base, making it irrelevant to this incision. **NEET-PG High-Yield Pearls:** 1. **Anatomical Landmark:** The mastoid process begins to develop at birth but only reaches significant size by age 2. 2. **Surgical Modification:** In infants, the retroauricular incision should be made more **superiorly and posteriorly** (more horizontal) to avoid the superficial facial nerve. 3. **Eustachian Tube:** In children, the tube is shorter, wider, and more horizontal, predisposing them to Otitis Media. 4. **External Auditory Canal:** In infants, the bony canal is absent; the canal consists only of a fibrocartilaginous portion.

Question 33: Which of the following anomalies are included in CHARGE Syndrome?

A. Choanal atresia
B. Coloboma of eye
C. Ear anomalies
D. All of the above (Correct Answer)

Explanation: **Explanation:** **CHARGE Syndrome** is a rare, complex genetic condition typically caused by a mutation in the **CHD7 gene** on chromosome 8. It is a high-yield topic in NEET-PG as it involves multiple systems, particularly the ear and airway. The diagnosis is based on a specific mnemonic where each letter represents a major clinical feature: * **C – Coloboma of the eye:** Most commonly affecting the retina or iris. * **H – Heart defects:** Such as Tetralogy of Fallot or PDA. * **A – Atresia of the choanae:** This is a classic ENT presentation; it can be unilateral or bilateral and is a life-threatening emergency in newborns. * **R – Retardation of growth and development.** * **G – Genitourinary anomalies:** Such as hypogonadism or undescended testes. * **E – Ear anomalies:** Characteristically includes "cup-shaped" ears, ossicular malformations, and sensorineural hearing loss. **Why "All of the above" is correct:** Options A, B, and C (Choanal atresia, Coloboma, and Ear anomalies) are the primary diagnostic pillars of the syndrome. Since all three are hallmark features, "All of the above" is the most accurate choice. **Clinical Pearls for NEET-PG:** 1. **CHD7 Gene:** The most common genetic association (found in >60-70% of cases). 2. **Ear Findings:** Beyond external ear shape, **Mondini dysplasia** (incomplete partitioning of the cochlea) is frequently associated with CHARGE. 3. **Airway Management:** Choanal atresia in these patients often requires surgical intervention (transnasal or transpalatal) shortly after birth. 4. **Major vs. Minor Criteria:** Coloboma, Choanal atresia, and characteristic Ear anomalies are considered **Major criteria** for diagnosis.

Question 34: A "thumb sign" on X-ray of the neck is characteristic of which of the following conditions?

A. Acute epiglottitis
B. Laryngotracheobronchitis (Correct Answer)
C. Laryngomalacia
D. Acute Bronchiolitis

Explanation: ### **Explanation** The **"Thumb Sign"** is a classic radiological hallmark of **Acute Epiglottitis**, not Laryngotracheobronchitis. *Note: There appears to be a discrepancy in the provided key. In standard medical literature and NEET-PG patterns, the Thumb Sign is diagnostic for Epiglottitis, while Laryngotracheobronchitis is associated with the "Steeple Sign."* #### **1. Why Acute Epiglottitis is the correct clinical association:** The "Thumb Sign" is seen on a **lateral view X-ray of the neck**. It represents a thickened, edematous epiglottis that loses its thin, leaf-like appearance and resembles the distal phalanx of a thumb. This is a medical emergency usually caused by *Haemophilus influenzae* type b (Hib). #### **2. Analysis of Incorrect Options:** * **Laryngotracheobronchitis (Croup):** Characterized by the **"Steeple Sign"** (subglottic narrowing) on an **Anteroposterior (AP) view** X-ray. It presents with a barking cough and inspiratory stridor, typically caused by the Parainfluenza virus. * **Laryngomalacia:** The most common cause of congenital stridor. Diagnosis is clinical or via flexible laryngoscopy (showing omega-shaped epiglottis); X-rays are usually unremarkable. * **Acute Bronchiolitis:** A lower respiratory tract infection (mostly RSV) presenting with wheezing and respiratory distress. X-rays show hyperinflation and peribronchial cuffing, not upper airway signs. #### **3. Clinical Pearls for NEET-PG:** * **Acute Epiglottitis:** Look for the "3 Ds": **D**rooling, **D**ysphagia, and **D**istress. The child often assumes the **Tripod position**. * **Management:** Never examine the throat with a tongue depressor as it may trigger fatal laryngospasm. Intubation in a controlled environment (OT) is the priority. * **Omega-shaped epiglottis:** Characteristic of Laryngomalacia. * **Steeple Sign vs. Thumb Sign:** Steeple = Croup (AP view); Thumb = Epiglottitis (Lateral view).

Question 35: A 10-year-old child presents with unilateral nasal obstruction, epistaxis, and swelling over the cheek. What is the most likely diagnosis?

A. Nasal polyp
B. Nasopharyngeal carcinoma
C. Angiofibroma (Correct Answer)
D. Foreign bodies

Explanation: ### Explanation The clinical triad of **unilateral nasal obstruction**, **recurrent epistaxis**, and **facial swelling** in a young male is a classic presentation of **Juvenile Nasopharyngeal Angiofibroma (JNA)**. **1. Why Angiofibroma is Correct:** JNA is a benign but locally aggressive, highly vascular tumor that typically arises from the sphenopalatine foramen. It occurs almost exclusively in adolescent males (median age 10–14 years). * **Epistaxis:** Occurs due to the tumor's extreme vascularity. * **Nasal Obstruction:** Caused by the mass filling the nasopharynx. * **Cheek Swelling:** Indicates extension into the pterygopalatine fossa and infratemporal fossa (Holman-Miller sign/Antral sign on imaging). **2. Why Other Options are Incorrect:** * **Nasal Polyp:** Usually presents with bilateral obstruction and watery rhinorrhea. While it can cause swelling (e.g., Ethmoidal polyp), it rarely causes significant epistaxis. * **Nasopharyngeal Carcinoma:** More common in adults (bimodal peak) and often presents with cervical lymphadenopathy and serous otitis media. While it can cause obstruction, the age and classic vascular symptoms point more strongly toward JNA. * **Foreign Bodies:** Typically present with unilateral, **foul-smelling, purulent** nasal discharge in younger children (2–5 years). While they can cause minor bleeding, they do not cause cheek swelling. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Contrast-Enhanced CT (CECT) or MRI. * **Holman-Miller Sign:** Anterior bowing of the posterior wall of the maxillary antrum on CT (Pathognomonic). * **Contraindication:** **Biopsy is strictly contraindicated** in the OPD due to the risk of torrential, life-threatening hemorrhage. * **Treatment of Choice:** Surgical excision (usually preceded by preoperative embolization to reduce blood loss).

Question 36: Laryngomalacia is characterized by?

A. Usually presents at about 5 years of age
B. Biphasic stridor
C. Elongated epiglottis with thin aryepiglottic folds on laryngoscopy (Correct Answer)
D. Best treatment by epiglottectomy

Explanation: **Laryngomalacia** is the most common congenital anomaly of the larynx and the most frequent cause of stridor in infants. It is characterized by an inward collapse of the supraglottic structures during inspiration due to abnormal flaccidity. ### **Explanation of the Correct Option** **C. Elongated epiglottis with thin aryepiglottic folds:** On flexible laryngoscopy, the classic findings include an elongated, "Omega-shaped" (Ω) epiglottis and shortened, thickened, or redundant aryepiglottic folds. These structures collapse into the laryngeal inlet during inspiration, causing airway obstruction. ### **Why Other Options are Incorrect** * **A. Age of presentation:** It typically presents at **birth or within the first 2 weeks of life**, not at 5 years. Stridor usually peaks at 6 months and resolves spontaneously by 18–24 months. * **B. Biphasic stridor:** Laryngomalacia classically presents with **inspiratory stridor** that worsens when the infant is supine, crying, or feeding. Biphasic stridor suggests a subglottic or fixed tracheal lesion. * **D. Best treatment:** The majority (90%) of cases are self-limiting and managed conservatively. If surgery is required (for failure to thrive or severe apnea), the procedure of choice is **Supraglottoplasty**, not epiglottectomy. ### **NEET-PG High-Yield Pearls** * **Diagnosis:** Flexible fiberoptic laryngoscopy in an awake, spontaneously breathing patient is the **Gold Standard**. * **Positioning:** Stridor improves when the infant is placed in the **prone position** (gravity pulls the supraglottic structures forward). * **Associated Condition:** Gastroesophageal reflux (GERD) is frequently associated and can worsen the edema and stridor. * **Omega-shaped epiglottis:** This is the most characteristic "buzzword" for exams.

Question 37: Which of the following is true about Pendred syndrome?

A. Diffuse colloid goiter
B. Nodular goiter
C. Mental retardation
D. All of the above (Correct Answer)

Explanation: **Explanation:** **Pendred Syndrome** is an autosomal recessive disorder caused by a mutation in the **SLC26A4 gene** on chromosome 7, which encodes the protein **pendrin**. Pendrin is an ion exchanger found in the inner ear and the thyroid gland. 1. **Thyroid Manifestations (Options A & B):** The defect in pendrin leads to impaired organification of iodine (positive **Perchlorate discharge test**). This results in a state of subclinical or overt hypothyroidism, leading to a compensatory increase in TSH. This chronic stimulation causes the thyroid to enlarge, initially presenting as a **diffuse colloid goiter**, which over time progresses into a **multinodular goiter**. 2. **Neurological Manifestations (Option C):** The syndrome is characterized by congenital **sensorineural hearing loss (SNHL)**. If the associated hypothyroidism is severe and untreated during the neonatal period, it can lead to cretinism and significant **mental retardation**. 3. **Inner Ear Findings:** Radiologically, it is classically associated with **Mondini dysplasia** (incomplete partition of the cochlea) and an **enlarged vestibular aqueduct (EVA)**. **Why "All of the above" is correct:** Pendred syndrome is a multisystem disorder. While the goiter may start as diffuse, it frequently becomes nodular, and the metabolic impact of thyroid dysfunction can lead to cognitive impairment. **High-Yield Clinical Pearls for NEET-PG:** * **Most common** cause of syndromic deafness. * **Diagnostic Test:** Perchlorate discharge test (shows >10-15% discharge of iodine). * **Imaging Gold Standard:** CT/MRI showing Enlarged Vestibular Aqueduct (EVA). * **Inheritance:** Autosomal Recessive.

Question 38: What is the commonest presentation of an infant with bilateral choanal atresia?

A. Difficulty in breathing (Correct Answer)
B. Dysphagia
C. Smiling
D. Difficulty in walking

Explanation: **Explanation:** **Bilateral Choanal Atresia** is a congenital condition where the posterior nasal apertures (choanae) are obstructed by bone (90%) or membrane (10%). **Why "Difficulty in Breathing" is correct:** Infants are **obligate nasal breathers** until approximately 4–6 months of age. In bilateral choanal atresia, the nasal airway is completely blocked, leading to immediate neonatal respiratory distress. A classic clinical hallmark is **cyclic cyanosis**: the infant turns blue (cyanotic) while resting or feeding (when the mouth is closed) and turns pink while crying (as they breathe through the oropharynx). This makes "Difficulty in breathing" the most common and life-threatening presentation. **Why the other options are incorrect:** * **Dysphagia:** While feeding is difficult because the infant cannot breathe and swallow simultaneously, the primary and most urgent presentation is respiratory, not a primary swallowing disorder. * **Smiling:** This is a developmental milestone (social smile) appearing around 2 months of age and is unrelated to the anatomical obstruction of the choanae. * **Difficulty in walking:** This is a gross motor milestone (typically 12 months) and is irrelevant to a neonatal structural airway emergency. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Failure to pass a 6F or 8F suction catheter through the nose into the nasopharynx. * **Investigation of Choice:** Non-contrast CT scan of the paranasal sinuses (shows narrowing of the posterior choana and thickening of the vomer). * **Immediate Management:** Insertion of a **McGovern nipple** (an oral airway with a large hole) to maintain an oropharyngeal airway. * **Definitive Treatment:** Surgical repair (Transnasal endoscopic approach is preferred). * **Association:** Often part of the **CHARGE syndrome** (Coloboma, Heart defects, Atresia choanae, Retarded growth, Genitourinary anomalies, Ear anomalies).

Question 39: A 5-year-old girl is admitted to the hospital with an upper respiratory tract infection. During physical examination her sense of hearing appears to be poor. Her right ear is painful, and upon otoscopic examination a golden-brown fluid can be observed through the tympanic membrane. Which is the most likely direct route for the spread of an infection from the upper respiratory tract to the middle ear cavity?

A. Pharyngotympanic tube (Correct Answer)
B. Choanae
C. Nostrils
D. Facial canal

Explanation: ### Explanation The correct answer is **A. Pharyngotympanic tube** (also known as the Eustachian tube). **1. Why the Pharyngotympanic Tube is Correct:** The middle ear cavity is an air-filled space that communicates directly with the nasopharynx via the **pharyngotympanic tube**. In children, this tube is shorter, wider, and more horizontal than in adults, making it the primary and most direct route for pathogens to ascend from the upper respiratory tract to the middle ear. The clinical presentation of "golden-brown fluid" behind the tympanic membrane suggests **Otitis Media with Effusion (OME)** or resolving Acute Otitis Media, both of which are typically preceded by Eustachian tube dysfunction following an upper respiratory infection. **2. Why the Other Options are Incorrect:** * **B. Choanae:** These are the posterior nasal apertures that connect the nasal cavity to the nasopharynx. While they are part of the respiratory tract, they do not lead directly to the middle ear. * **C. Nostrils:** These are the anterior openings of the nasal cavity. They are the entry point for infections into the respiratory system but have no direct anatomical connection to the ear. * **D. Facial canal:** This is a bony passage in the temporal bone for the facial nerve (CN VII). While the facial nerve passes through the middle ear, the canal is not a route for the spread of infection from the pharynx. **3. NEET-PG High-Yield Pearls:** * **Anatomy:** The Eustachian tube connects the anterior wall of the middle ear to the lateral wall of the nasopharynx. * **Pediatric Difference:** The shorter and more horizontal tube in children is the most common reason for the high incidence of **Otitis Media** in the pediatric age group. * **Otoscopic Finding:** A "golden-yellow" or "amber" appearance of the tympanic membrane is a classic sign of serous fluid (Otitis Media with Effusion). * **Muscles:** The *Tensor veli palatini* is the primary muscle responsible for opening the Eustachian tube during swallowing or yawning.

Question 40: A 4-year-old male presents with recurrent upper respiratory tract infections, difficulty breathing, high arched palate, failure to grow, and impaired hearing. What is the most appropriate management?

A. Tonsillectomy
B. Adenoidectomy
C. Antibiotics and nasal decongestants
D. Adenoidectomy with grommet insertion (Correct Answer)

Explanation: ### Explanation The clinical presentation describes a classic case of **Adenoid Hypertrophy** complicated by **Otitis Media with Effusion (OME)**. **1. Why Option D is Correct:** * **Adenoid Hypertrophy:** Recurrent URIs, difficulty breathing (mouth breathing), and a **high arched palate** (due to persistent mouth breathing during facial development) are hallmark signs. Adenoidectomy is the definitive surgical treatment to relieve the airway obstruction. * **Impaired Hearing:** In children, enlarged adenoids obstruct the **Eustachian tube orifice**, leading to negative middle ear pressure and fluid accumulation (OME/Glue Ear). This causes conductive hearing loss. * **Grommet Insertion (Myringotomy with Ventilation Tube):** This is required to drain the middle ear fluid and restore hearing. In pediatric cases where adenoid hypertrophy is the primary cause of Eustachian tube dysfunction, combined **Adenoidectomy with Grommet insertion** is the gold standard management. **2. Why Other Options are Incorrect:** * **Option A:** Tonsillectomy is indicated for recurrent tonsillitis or obstructive sleep apnea (OSA). While often done together (Adenotonsillectomy), the specific symptoms here (nasal obstruction and hearing loss) point primarily to the adenoids. * **Option B:** Adenoidectomy alone addresses the airway but fails to treat the existing middle ear effusion and hearing loss. * **Option C:** Medical management is usually the first line for acute infections, but the presence of structural changes (high arched palate) and "failure to grow" (suggestive of chronic OSA) necessitates surgical intervention. **3. NEET-PG High-Yield Pearls:** * **Adenoid Facies:** Characterized by an open mouth, prominent upper incisors, hitched-up upper lip, and a high arched palate. * **Failure to Thrive:** Chronic airway obstruction in children can lead to nocturnal hypoxia and reduced growth hormone secretion. * **Investigation of Choice:** Lateral X-ray of the nasopharynx (soft tissue neck) or diagnostic nasal endoscopy. * **Most common cause of hearing loss in children:** Otitis Media with Effusion.

Practice by Chapter

Congenital Anomalies of the Ear

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Pediatric Hearing Loss

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Otitis Media in Children

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Pediatric Sinusitis

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Pediatric Sleep Apnea

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Stridor in Children

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Congenital Airway Anomalies

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Foreign Body Management

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Pediatric Head and Neck Masses

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Pediatric Tracheostomy

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Pediatric Voice Disorders

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Pierre Robin Sequence and Airway Management

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