Pediatric Otolaryngology Practice Questions

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

Laryngomalacia. **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).

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

All of the above. **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.

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

Laryngotracheobronchitis. ### **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).

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

Angiofibroma. ### 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).

Q: Which of the following is true about Pendred syndrome?

All of the above. **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.

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

Difficulty in breathing. **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 1

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

Accepted Answer

Laryngomalacia

Answer

Abductor vocal cord palsy

Answer

Croup

Answer

Epiglottitis

Question 2

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

Accepted Answer

Cranial Nerve VI

Answer

Cranial Nerve VIII

Answer

Cranial Nerve VII

Answer

Cranial Nerve V

Question 3

Which of the following anomalies are included in CHARGE Syndrome?

Accepted Answer

All of the above

Answer

Choanal atresia

Answer

Coloboma of eye

Answer

Ear anomalies

Question 4

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

Accepted Answer

Laryngotracheobronchitis

Answer

Acute epiglottitis

Answer

Laryngomalacia

Answer

Acute Bronchiolitis

Question 5

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

Accepted Answer

Angiofibroma

Answer

Nasal polyp

Answer

Nasopharyngeal carcinoma

Answer

Foreign bodies

Question 6

Laryngomalacia is characterized by?

Accepted Answer

Elongated epiglottis with thin aryepiglottic folds on laryngoscopy

Answer

Usually presents at about 5 years of age

Answer

Biphasic stridor

Answer

Best treatment by epiglottectomy

Question 7

Which of the following is true about Pendred syndrome?

Accepted Answer

All of the above

Answer

Diffuse colloid goiter

Answer

Nodular goiter

Answer

Mental retardation

Question 8

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

Accepted Answer

Difficulty in breathing

Answer

Dysphagia

Answer

Smiling

Answer

Difficulty in walking

Question 9

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?

Accepted Answer

Pharyngotympanic tube

Answer

Choanae

Answer

Nostrils

Answer

Facial canal

Question 10

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?

Accepted Answer

Adenoidectomy with grommet insertion

Answer

Tonsillectomy

Answer

Adenoidectomy

Answer

Antibiotics and nasal decongestants

Pediatric Otolaryngology — MCQs

Pediatric Otolaryngology — MCQs

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