Pediatric Otolaryngology Practice Questions

Q: A 2-year-old was brought to the emergency department with difficulty swallowing for the last few hours. The X-ray is given below. Which is the next best step to manage this patient?

Esophagoscopy. ***Esophagoscopy*** - The X-ray shows a circular radiopaque object, the classic **"coin sign"** on an anteroposterior view, which is characteristic of a foreign body lodged in the **esophagus**. - **Esophagoscopy** is the definitive procedure for both visualizing and safely removing the foreign object, especially important if it is a button battery which can cause rapid mucosal injury. *Bronchoscopy* - This procedure is indicated for the removal of foreign bodies from the **airways** (trachea or bronchi), not the esophagus. - A tracheal foreign body would typically present with **respiratory distress** (stridor, wheezing) and would appear as a thin line on an AP X-ray because it would be oriented in the sagittal plane. *Tracheostomy* - A tracheostomy is a surgical procedure to create an alternative airway and is reserved for severe **upper airway obstruction** or the need for long-term mechanical ventilation. - This patient's primary problem is **dysphagia** (difficulty swallowing) due to an esophageal obstruction, not an airway emergency requiring a surgical airway. *Heimlich's manoeuvre* - This is an emergency first-aid procedure used for acute **choking** caused by a foreign body obstructing the airway, leading to an inability to breathe or speak. - The patient is not described as actively choking and has a stable airway; therefore, this maneuver is inappropriate and could cause harm.

Q: Which of the following diagnoses can cause stridor in infants? 1. Laryngomalacia 2. Congenital hemangioma 3. Subglottic stenosis 4. Recurrent respiratory papillomatosis (RRP)

1, 3 and 4. ***1, 3 and 4*** - This option correctly identifies the three most common and clinically significant causes of stridor in infants - **Laryngomalacia (1)** is the most common cause of congenital stridor (60-75% of cases), presenting with inspiratory stridor that worsens with agitation - **Subglottic stenosis (3)** is the second most common cause of congenital stridor, presenting with biphasic stridor and may be congenital or acquired - **Recurrent respiratory papillomatosis/RRP (4)** caused by HPV (types 6 and 11) causes progressive airway obstruction with stridor and hoarseness - While congenital (subglottic) hemangiomas can cause stridor, they are less common than the above three conditions and typically present between 1-3 months of age *Incorrect: 1 and 3* - This option is incomplete as it excludes **RRP (4)**, which is an important cause of pediatric airway obstruction - RRP typically presents in early childhood and requires serial surgical debulking *Incorrect: 2 and 3* - This option incorrectly excludes **Laryngomalacia (1)**, which is the single most common cause of stridor in infants - Missing laryngomalacia in the differential diagnosis would be a significant oversight *Incorrect: 1 and 4* - This option fails to include **Subglottic stenosis (3)**, the second most common cause of congenital stridor - Subglottic stenosis can be life-threatening and requires urgent evaluation and management

Q: What is the most common indication of tracheostomy in a child?

Vocal cord paralysis. ***Vocal cord paralysis*** - Among the options listed, **vocal cord paralysis** is the most appropriate answer as it remains a relevant pediatric indication for tracheostomy in current practice. - **Bilateral vocal cord paralysis** can cause significant airway obstruction requiring tracheostomy, especially in congenital cases or after cardiac surgery. - Note: In modern pediatric practice, the overall most common indications are **prolonged mechanical ventilation** and **congenital airway anomalies**, but among the specific causes listed here, vocal cord paralysis is the best answer. *Laryngeal diphtheria* - While **laryngeal diphtheria** historically was a common cause of pediatric tracheostomy due to pseudomembrane formation causing severe airway obstruction, its incidence has drastically decreased with **widespread immunization programs**. - In the pre-vaccination era, this was indeed a leading indication, but it is now rare in countries with effective vaccination coverage. *Poliomyelitis* - **Poliomyelitis** can affect respiratory muscles leading to ventilatory failure requiring tracheostomy, but with **global eradication efforts and vaccination**, it is now extremely rare. - This was a significant historical indication but is no longer relevant in most parts of the world. *Carcinoma of larynx* - **Laryngeal carcinoma** is predominantly an adult malignancy with peak incidence in the 6th-7th decades, associated with smoking and alcohol use. - It is **extremely rare in the pediatric population**, making it the least likely indication for tracheostomy in children among all the options listed.

Q: What is the most common complication occurring in tracheostomy in children? (March 2004)

Infection. ***Infection*** - **Infection** is the most common complication in pediatric tracheostomy, occurring in **50-60% of cases** due to the open wound, bypassed upper airway defenses, and frequent suctioning requirements. - Can manifest as **stoma infections** (cellulitis, wound breakdown), **tracheitis**, **pneumonia**, or **mediastinitis** requiring active management. *Difficult decannulation* - A **long-term complication** that occurs frequently in pediatric cases due to **granulation tissue formation**, **suprastomal collapse**, and **tracheomalacia**. - While common, it is a **secondary issue** that develops over time rather than an immediate post-operative complication. *Difficult weaning* - Refers to challenges in **ventilator weaning** which is more related to the **underlying respiratory or neurological condition** rather than a direct tracheostomy complication. - Represents a **management challenge** rather than a procedural complication of the tracheostomy itself. *Stenosis* - **Tracheal or subglottic stenosis** is a serious **late complication** occurring in only **10-15% of pediatric cases**. - Results from **chronic irritation**, **granulation tissue**, or cartilage injury, but has a **lower overall incidence** compared to infection despite children's narrow airways.

Q: A 6-year-old boy presents with a history of mouth breathing and snoring. On examination, he has enlarged tonsils and adenoids. What is the first-line treatment?

Adenotonsillectomy. ***Adenotonsillectomy*** - **First-line definitive treatment** for children with adenotonsillar hypertrophy causing **symptomatic obstruction** such as persistent mouth breathing and snoring - Indications for surgery include **obstructive sleep-disordered breathing**, chronic mouth breathing, failure to thrive, and recurrent infections - This 6-year-old has clear **functional impairment** (mouth breathing + snoring) requiring surgical intervention - According to **AAO-HNS guidelines**, adenotonsillectomy is recommended for children with enlarged tonsils/adenoids causing sleep-disordered breathing or obstructive symptoms *Observation* - Appropriate for **asymptomatic or minimally symptomatic** adenotonsillar hypertrophy - May be considered when enlargement is noted incidentally without functional impairment - Not suitable for this patient who has **symptomatic obstruction** (mouth breathing and snoring indicate significant airway compromise) - Delaying treatment in symptomatic children can lead to complications like craniofacial abnormalities, poor growth, and behavioral issues *Steroid nasal spray* - May provide some benefit for **isolated adenoid hypertrophy** causing nasal obstruction - Generally considered an **adjunctive or temporizing measure**, not first-line treatment - Less effective when both tonsils and adenoids are enlarged - Cannot address tonsillar hypertrophy component *Antibiotics* - Indicated for **acute bacterial tonsillitis or adenoiditis** - Not appropriate for **chronic anatomical enlargement** causing obstructive symptoms - No evidence of acute infection in this clinical scenario - Would not resolve the underlying mechanical obstruction

Q: Most common impacted foreign body in esophagus in children is

Coin. ***Coin:*** - **Coins** are the most frequently encountered foreign bodies ingested by children, often becoming lodged in the esophagus due to their shape and size. - The **cricopharyngeal muscle** or the **aortic arch** are common impaction sites for coins in the esophagus. *Food product:* - While food products can cause esophageal obstruction in children, they are more often associated with **strictures** or underlying esophageal motility disorders. - **Smaller, chewable food items** are less likely to cause a complete or prolonged impaction compared to smooth, solid objects like coins. *Crayon:* - **Crayons** are typically made of wax and pigment, making them relatively soft and less likely to cause complete esophageal obstruction or retain a fixed position. - Their irregular shape and friable nature mean they might be more easily dislodged or pass through compared to a rigid coin. *Marble:* - **Marbles** can certainly become impacted in the esophagus, and their smooth, spherical shape poses a risk of complete obstruction. - However, they are **less commonly ingested** by children compared to coins, which are more readily available and often mistaken as playthings.

Q: What is the preferred method for removing a foreign body from the lung in children?

Rigid bronchoscopy. ***Rigid bronchoscopy*** - **Rigid bronchoscopy** is the preferred method for removing foreign bodies from the lung in children due to its ability to provide better air control, magnified viewing, and larger working channels for robust grasping tools. - It allows for complete ventilation control and isolation of the airway, which is crucial in children where airway obstruction can rapidly lead to respiratory compromise. *Chest x-ray* - A **chest x-ray** is a diagnostic tool used to identify the presence and location of a foreign body, but it is not a method for removal. - Many foreign bodies, especially non-radiopaque ones like food, may not be visible on an x-ray, making it unreliable for definitive diagnosis of presence or absence. *Flexible endoscopy* - While **flexible bronchoscopy** can be used for foreign body removal in some adults or specific situations, it is generally less effective and carries higher risks in children, especially for larger or lodged objects. - Its smaller working channels and less stable airway control make it less suitable for urgent and complete removal in the pediatric population. *Direct laryngoscopy* - **Direct laryngoscopy** is used to visualize the larynx and vocal cords, primarily to remove foreign bodies from the upper airway or intubate, but not typically for removal of foreign bodies lodged deep within the main bronchi or lungs. - It does not offer direct access or visualization of the lower bronchial tree where most aspirated foreign bodies in children tend to lodge.

Q: Best management for an inhaled foreign body in an infant is?

Bronchoscopy. ***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**.

Q: Most common cause of epistaxis in a 3-year-old child is:

Foreign body. ***Foreign body*** - Young children, especially around 3 years old, are prone to inserting **foreign bodies** into their nostrils. - This is one of the most important causes of **epistaxis** in this age group, particularly when unilateral or recurrent. - Can mechanically irritate and traumatize the nasal mucosa leading to bleeding. *Upper respiratory catarrh* - **Upper respiratory infections** (common cold) are actually a very frequent cause of epistaxis in children. - However, the bleeding is usually mild and self-limiting, caused by **friable, inflamed nasal mucosa**. - Among the given options and considering clinically significant epistaxis requiring evaluation, foreign body is the more important diagnosis to consider. *Nasal polyp* - **Nasal polyps** are relatively uncommon in young children and are not a frequent cause of epistaxis in this age group. - When they do occur, they are often associated with conditions like **cystic fibrosis** or chronic sinusitis. *Atrophic rhinitis* - **Atrophic rhinitis** is a chronic inflammatory condition characterized by **atrophy of the nasal mucosa** and turbinates. - It is predominantly seen in adults, not typically in a 3-year-old child.

Question 1

A 2-year-old was brought to the emergency department with difficulty swallowing for the last few hours. The X-ray is given below. Which is the next best step to manage this patient?

Accepted Answer

Esophagoscopy

Answer

Bronchoscopy

Answer

Heimlich's manoeuvre

Answer

Tracheostomy

Question 2

Which of the following diagnoses can cause stridor in infants?

1. Laryngomalacia
2. Congenital hemangioma
3. Subglottic stenosis
4. Recurrent respiratory papillomatosis (RRP)

Accepted Answer

1, 3 and 4

Answer

1 and 3

Answer

2 and 3

Answer

1 and 4

Question 3

What is the most common indication of tracheostomy in a child?

Accepted Answer

Vocal cord paralysis

Answer

Laryngeal diphtheria

Answer

Poliomyelitis

Answer

Carcinoma of larynx

Question 4

What is the most common complication occurring in tracheostomy in children? (March 2004)

Accepted Answer

Infection

Answer

Difficult decannulation

Answer

Difficult weaning

Answer

Stenosis

Question 5

A 6-year-old boy presents with a history of mouth breathing and snoring. On examination, he has enlarged tonsils and adenoids. What is the first-line treatment?

Accepted Answer

Adenotonsillectomy

Answer

Antibiotics

Answer

Observation

Answer

Steroid nasal spray

Question 6

Most common impacted foreign body in esophagus in children is

Accepted Answer

Coin

Answer

Food product

Answer

Marble

Answer

Crayon

Question 7

What is the preferred method for removing a foreign body from the lung in children?

Accepted Answer

Rigid bronchoscopy

Answer

Chest x-ray

Answer

Flexible endoscopy

Answer

Direct laryngoscopy

Question 8

Best management for an inhaled foreign body in an infant is?

Accepted Answer

Bronchoscopy

Answer

IPPV

Answer

Tracheostomy

Answer

Corticosteroids

Question 9

Most common cause of epistaxis in a 3-year-old child is:

Accepted Answer

Foreign body

Answer

Nasal polyp

Answer

Atrophic rhinitis

Answer

Upper respiratory catarrh

Pediatric Otolaryngology — MCQs

Pediatric Otolaryngology — MCQs

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