Pediatric Otolaryngology — MCQs

A two-year-old child with a history of purulent nasal discharge and fever presents with conjunctival congestion and edema. His temperature is 102-103°F and WBC count is 12,000. The culture of eye discharge was negative, and X-rays show opacification of the ethmoid sinus. What is the next step in evaluating this patient?

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A child presents with an expansile swelling on the medial side of the nose. What is the likely diagnosis?

Pediatric Otolaryngology Indian Medical PG Practice Questions and MCQs

Question 41: What is the most common cause of congenital stridor in a child?

A. Laryngomalacia (Correct Answer)
B. Laryngeal web
C. Hemangioma
D. Subglottic stenosis

Explanation: **Laryngomalacia** is the most common cause of congenital stridor, accounting for approximately 60–70% of cases. It is characterized by an inward collapse of the supraglottic structures (epiglottis, aryepiglottic folds, and arytenoids) during inspiration due to excessive flaccidity of the laryngeal tissues. ### Why Laryngomalacia is Correct: The hallmark clinical presentation is **inspiratory stridor** that typically appears within the first two weeks of life. The stridor characteristically increases when the infant is supine, crying, or feeding, and improves when the infant is placed in a prone position. Diagnosis is confirmed via flexible fiberoptic laryngoscopy, which reveals an **omega-shaped epiglottis** and shortened aryepiglottic folds. ### Why Other Options are Incorrect: * **Laryngeal web:** A rare congenital anomaly resulting from incomplete recanalization of the larynx. It typically presents with a weak cry or aphonia at birth, rather than isolated stridor. * **Hemangioma:** Subglottic hemangiomas usually present between 1–6 months of age (not at birth) and often present with biphasic stridor. * **Subglottic stenosis:** This is the third most common cause of congenital stridor. While it can be congenital, it is more frequently acquired due to prolonged intubation in neonates. ### NEET-PG High-Yield Pearls: * **Most common site of involvement:** Supraglottis. * **Classic finding:** Omega-shaped (Ω) epiglottis. * **Management:** Most cases (90%) are self-limiting and resolve by 18–24 months. Surgical intervention (**Supraglottoplasty**) is only indicated in severe cases involving failure to thrive, cor pulmonale, or severe apnea. * **Second most common cause of congenital stridor:** Vocal cord paralysis.

Question 42: A 3-year-old child presents with fever and earache. On examination, there is a congested tympanic membrane with a slight bulge. What is the recommended treatment?

A. Myringotomy with penicillin
B. Myringotomy with grommet
C. Antibiotics only (Correct Answer)
D. Observe and wait

Explanation: **Explanation:** The clinical presentation of fever, earache, and a congested, bulging tympanic membrane (TM) in a 3-year-old is diagnostic of **Acute Otitis Media (AOM)** in the **Stage of Suppuration**. 1. **Why "Antibiotics only" is correct:** The primary treatment for AOM in the suppurative stage is systemic antibiotics (typically Amoxicillin as the first line). At this stage, pus is under pressure in the middle ear, but it has not yet perforated the TM. Antibiotics effectively control the infection, resolve the inflammation, and prevent complications. In pediatric patients, medical management is the gold standard before considering surgical intervention. 2. **Why other options are incorrect:** * **Myringotomy with penicillin (A):** Myringotomy is reserved for cases with severe pain, impending complications, or failure of medical therapy. It is not the first-line treatment for uncomplicated AOM. * **Myringotomy with grommet (B):** Grommet insertion is indicated for **Otitis Media with Effusion (OME)** or recurrent AOM, not for an acute primary episode. * **Observe and wait (D):** While "watchful waiting" is an option for older children with mild, unilateral symptoms, a 3-year-old with fever and a bulging TM requires active antibiotic treatment to prevent progression to the Stage of Perforation or Mastoiditis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organism:** *Streptococcus pneumoniae* (followed by *H. influenzae* and *M. catarrhalis*). * **Stages of AOM:** Tubal occlusion → Vascular congestion → Suppuration (bulging TM) → Perforation (discharge) → Resolution. * **Myringotomy Site:** Always performed in the **postero-inferior quadrant** to avoid injury to the ossicles (incus/stapes) and the chorda tympani nerve. * **Cartwheel Appearance:** Seen in the Stage of Congestion due to radiating vessels on the TM.

Question 43: What is the most common cause of conductive deafness in children less than 12 years of age?

A. Chronic suppurative otitis media (CSOM)
B. Otosclerosis
C. Serous otitis media (Correct Answer)
D. Atresia of the auditory canals on both sides

Explanation: **Explanation:** **1. Why Serous Otitis Media (SOM) is the Correct Answer:** Serous Otitis Media (also known as Otitis Media with Effusion - OME) is the most common cause of conductive hearing loss (CHL) in the pediatric population. The underlying pathophysiology is primarily **Eustachian tube dysfunction**, which is more prevalent in children due to the tube being shorter, wider, and more horizontal compared to adults. This leads to negative middle ear pressure and the accumulation of sterile fluid, resulting in a "Glue Ear." It typically presents with a painless, fluctuating hearing loss and a Type B (flat) tympanogram. **2. Analysis of Incorrect Options:** * **Chronic Suppurative Otitis Media (CSOM):** While a significant cause of hearing loss in developing countries, it is less common than SOM. CSOM involves a permanent perforation of the tympanic membrane and active infection, whereas SOM is often a silent, non-infectious accumulation of fluid. * **Otosclerosis:** This is a primary disease of the bony labyrinth characterized by stapedial fixation. It typically manifests in the **3rd to 4th decades of life** and is rare in children under 12. * **Atresia of the Auditory Canals:** This is a congenital structural anomaly. While it causes severe conductive deafness, it is a rare condition compared to the high incidence of middle ear effusions in school-going children. **3. NEET-PG High-Yield Pearls:** * **Investigation of Choice:** Impedance Audiometry (Tympanometry) – typically shows a **Type B curve**. * **Management:** Most cases resolve spontaneously. If persistent (>3 months), the surgical treatment of choice is **Myringotomy with Grommet insertion**. * **Associated Condition:** In children with recurrent SOM, always evaluate for **Adenoid Hypertrophy**, as it is the most common cause of Eustachian tube blockage in this age group.

Question 44: A swelling that becomes more prominent at the root of the nose as a child cries is most probably?

A. Meningocele (Correct Answer)
B. Stewart's granuloma
C. Wegner's granuloma
D. Aspergillosis

Explanation: ### Explanation **Correct Option: A. Meningocele** The clinical presentation of a congenital midline nasal swelling that enlarges or becomes more prominent when the child cries, coughs, or strains is a classic sign of an **Encephalocele** or **Meningocele**. * **Mechanism:** This phenomenon is known as a **positive Furstenberg test**. When a child cries or strains, the intracranial pressure (ICP) increases. Since a meningocele is a herniation of the meninges through a bony defect in the skull base (often at the *foramen caecum*), this rise in ICP is transmitted directly to the sac, causing it to expand and become more tense/prominent. * **Diagnosis:** These masses are typically soft, bluish, and pulsatile. They do not transilluminate as well as gliomas, but they are distinguished by their connection to the subarachnoid space. **Why Incorrect Options are Wrong:** * **B. Stewart’s Granuloma:** Now known as NK/T-cell lymphoma (nasal type). It is a highly aggressive, midline lethal granuloma causing extensive tissue destruction, typically seen in adults, not as a congenital swelling in children. * **C. Wegener’s Granulomatosis:** A systemic vasculitis (GPA) that causes crusting, epistaxis, and "saddle nose" deformity. It is an acquired inflammatory condition, not a congenital mass that fluctuates with ICP. * **D. Aspergillosis:** A fungal infection (either non-invasive or invasive) that presents with sinus symptoms or a fungal ball. It does not present as a midline nasal root swelling that responds to crying. **High-Yield Clinical Pearls for NEET-PG:** 1. **Furstenberg Test:** Positive in Encephalocele/Meningocele; Negative in Nasal Glioma (as gliomas are sequestered and lack a patent CSF connection). 2. **Radiology:** MRI is the investigation of choice to rule out intracranial extension before any surgical intervention or biopsy. 3. **Biopsy Contraindication:** Never biopsy a midline nasal mass in a child until intracranial extension is ruled out, due to the high risk of **CSF rhinorrhea and meningitis**. 4. **Nasal Glioma:** Often described as "firm" and "non-compressible," unlike the soft, compressible nature of a meningocele.

Question 45: An infant is brought with stridor and diagnosed with laryngomalacia. Which of the following findings is NOT typically seen in this condition?

A. Stridor is inspiratory
B. Floppy epiglottis folds
C. Hoarse cry (Correct Answer)
D. Prominent arytenoids

Explanation: **Explanation:** **Laryngomalacia** is the most common cause of congenital stridor. It is characterized by the collapse of supraglottic structures during inspiration due to abnormal flaccidity of the laryngeal tissues. **Why "Hoarse Cry" is the correct answer:** In laryngomalacia, the pathology is strictly **supraglottic** (above the vocal cords). Since the vocal cords themselves are normal and vibrate properly, the infant’s cry remains clear and loud. A hoarse cry would instead suggest a glottic pathology, such as laryngeal webs, vocal cord palsy, or subglottic stenosis. **Analysis of Incorrect Options:** * **A. Inspiratory Stridor:** This is the hallmark of laryngomalacia. As the infant breathes in, the negative pressure causes the floppy supraglottic tissues to collapse inward, creating a high-pitched sound. The stridor typically worsens when the infant is supine, crying, or feeding. * **B. Floppy epiglottis folds:** On laryngoscopy, the epiglottis is often seen as "omega-shaped" ($\Omega$) and folds in on itself due to its flaccid nature. * **C. Prominent arytenoids:** Bulky, redundant mucosa over the arytenoids and short aryepiglottic folds are classic endoscopic findings that contribute to the collapse of the airway. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of collapse:** Aryepiglottic folds. * **Diagnosis:** Flexible fiberoptic laryngoscopy (gold standard) showing inward collapse of supraglottic structures. * **Management:** Most cases (90%) are managed **expectantly** as they resolve by 18–24 months. * **Surgical Intervention:** **Supraglottoplasty** is indicated only in severe cases (failure to thrive, cor pulmonale, or severe apnea). * **Associated Condition:** Gastroesophageal reflux (GERD) is frequently associated and can worsen the stridor.

Question 46: For juvenile angiofibroma confined to the nasal cavity, what is the preferred surgical approach?

A. Transnasal endoscopic (Correct Answer)
B. Transpalatal
C. Lateral rhinotomy
D. Transmaxillary

Explanation: **Explanation:** Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign but locally aggressive, highly vascular tumor. The choice of surgical approach depends primarily on the **Fisch or Radkowski stage** (extent of the tumor). **Why Transnasal Endoscopic is Correct:** For tumors confined to the nasal cavity, nasopharynx, or sphenoid sinus (Stage I and early Stage II), the **Transnasal Endoscopic approach** is now the gold standard. It offers superior visualization, avoids external facial scars, reduces intraoperative blood loss, and results in shorter hospital stays. With modern instrumentation and preoperative embolization, even tumors extending into the pterygopalatine fossa can be managed endoscopically. **Why Other Options are Incorrect:** * **B. Transpalatal:** Historically used for nasopharyngeal tumors, but it provides limited exposure to the superior and lateral extensions and carries a high risk of palatal fistula and dental malocclusion. * **C. Lateral Rhinotomy:** An external approach that provides good exposure but is reserved for very large tumors with extensive lateral or orbital involvement. It is avoided for small tumors due to the resulting facial scar and potential for midface growth retardation in pediatric patients. * **D. Transmaxillary (Caldwell-Luc/Medial Maxillectomy):** Used for tumors involving the maxillary sinus or infratemporal fossa, but it is more invasive than the endoscopic approach for tumors limited to the nasal cavity. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Adolescent male + Profuse recurrent epistaxis + Nasal obstruction. * **Origin:** Usually the superior border of the sphenopalatine foramen. * **Holman-Miller Sign:** Anterior bowing of the posterior wall of the maxillary sinus seen on CT (pathognomonic). * **Pre-op Management:** Digital Subtraction Angiography (DSA) followed by **embolization** (24–48 hours before surgery) is mandatory to minimize life-threatening hemorrhage. * **Biopsy is contraindicated** due to the risk of torrential bleeding.

Question 47: The most common site of the internal opening of a bronchial fistula is at which location?

A. Lateral nasopharyngeal wall
B. Fossa of Rosenmuller
C. Gingivo-labial sulcus
D. Tonsillar fossa (Correct Answer)

Explanation: **Explanation:** The question refers to the **Second Branchial Arch Fistula**, which is the most common type of branchial fistula (95% of cases). **1. Why the Tonsillar Fossa is correct:** Branchial fistulae are the result of the failure of the second branchial cleft and the cervical sinus of His to obliterate. The tract of a second branchial fistula follows a specific embryological path: it starts at an external opening along the lower third of the sternocleidomastoid muscle, ascends along the carotid sheath, passes **between the internal and external carotid arteries**, and pierces the superior constrictor muscle to open internally. The internal opening is consistently located in the **tonsillar fossa** (specifically on the posterior pillar or the intratonsillar cleft). **2. Analysis of Incorrect Options:** * **Lateral nasopharyngeal wall / Fossa of Rosenmuller:** These are related to the **first branchial pouch** (Eustachian tube development). A first branchial cleft fistula typically opens into the external auditory canal. * **Gingivo-labial sulcus:** This is the site for a **Congenital Orofacial Fistula** or may be associated with dental pathology, but it is not a site for branchial arch derivatives. **3. High-Yield Clinical Pearls for NEET-PG:** * **First Branchial Fistula:** Opens into the External Auditory Canal (EAC). * **Second Branchial Fistula:** Most common; opens in the **Tonsillar Fossa**; passes between the carotids. * **Third Branchial Fistula:** Opens into the **Pyriform Sinus** (above the superior laryngeal nerve). * **Fourth Branchial Fistula:** Opens into the **Apex of the Pyriform Sinus** (below the superior laryngeal nerve); often associated with recurrent left-sided thyroid abscesses. * **Investigation of Choice:** Fistulogram (to delineate the tract).

Question 48: A 4-year-old girl scheduled for tonsillectomy presents with a painless, mobile, cystic midline neck swelling measuring 2 x 1.1 x 1 cm, located just below the hyoid bone. Ultrasound revealed a thick-walled cystic lesion. What is the recommended management for this condition?

A. Surgical removal (Correct Answer)
B. Antibiotics
C. Percutaneous aspiration
D. Chest X-ray

Explanation: ### Explanation **Diagnosis: Thyroglossal Duct Cyst (TGDC)** The clinical presentation of a **painless, mobile, midline neck swelling** in a child, specifically located near the hyoid bone, is classic for a Thyroglossal Duct Cyst. This occurs due to the failure of the thyroglossal duct to obliterate during the descent of the thyroid gland from the foramen caecum to its adult position. **1. Why Surgical Removal is Correct:** The definitive management for a TGDC is surgical excision, specifically the **Sistrunk Operation**. This procedure involves removing the cyst, the entire tract, and the **central portion of the hyoid bone** to minimize the high risk of recurrence. Surgery is recommended even if asymptomatic to prevent recurrent infections, abscess formation, or the rare risk of papillary thyroid carcinoma (1%). **2. Why Other Options are Incorrect:** * **Antibiotics:** These are only indicated if the cyst becomes acutely infected (thyroglossal duct abscess). They do not treat the underlying anatomical defect. * **Percutaneous Aspiration:** This is contraindicated as a primary treatment because it carries a high risk of infection and does not prevent recurrence. It is only used for diagnostic cytology if malignancy is suspected. * **Chest X-ray:** This has no role in the diagnosis or management of a midline neck swelling. However, an **Ultrasound of the neck** is vital to confirm the presence of a normal thyroid gland in its anatomical position before surgery. **3. NEET-PG High-Yield Pearls:** * **Movement:** TGDC is unique because it **moves upwards on protrusion of the tongue** (due to its attachment to the hyoid/foramen caecum) and on deglutition. * **Most Common Site:** Sub-hyoid (as seen in this case). * **Sistrunk Procedure:** Key step is the removal of the body of the hyoid bone. * **Differential Diagnosis:** Dermoid cyst (does not move with tongue protrusion) and Ectopic Thyroid (must be ruled out via USG).

Question 49: A two-year-old child with a history of purulent nasal discharge and fever presents with conjunctival congestion and edema. His temperature is 102-103°F and WBC count is 12,000. The culture of eye discharge was negative, and X-rays show opacification of the ethmoid sinus. What is the next step in evaluating this patient?

A. CT Scan (Correct Answer)
B. Urine Culture
C. Blood culture
D. Repeat culture of eye discharge

Explanation: **Explanation:** The clinical presentation of a child with fever, purulent nasal discharge, ethmoid opacification, and ocular symptoms (conjunctival congestion and edema) is highly suggestive of **Orbital Complications of Acute Sinusitis**. In children, the ethmoid sinus is the most common source of orbital infection due to the thinness of the *lamina papyracea*. **Why CT Scan is the correct answer:** The primary goal in this scenario is to differentiate between **Preseptal Cellulitis** (managed medically) and **Orbital Cellulitis/Abscess** (which may require surgical intervention). A **Contrast-Enhanced CT (CECT) of the Orbits and Paranasal Sinuses** is the gold standard for evaluating the extent of the disease, identifying subperiosteal abscesses, and planning surgical drainage. It is the immediate next step when ocular signs (edema/congestion) appear in the context of sinusitis. **Why other options are incorrect:** * **Blood Culture:** While useful for systemic management, it does not help in staging the orbital complication or determining the need for surgery. * **Urine Culture:** Irrelevant to the diagnosis of sinusitis or its orbital complications. * **Repeat Eye Discharge Culture:** Often negative (as seen here) because the infection is deep within the orbital tissues or sinuses, not a primary superficial conjunctivitis. **Clinical Pearls for NEET-PG:** * **Chandler’s Classification:** Used to stage orbital complications (I: Preseptal, II: Orbital cellulitis, III: Subperiosteal abscess, IV: Orbital abscess, V: Cavernous sinus thrombosis). * **Most common sinus involved:** Ethmoid (in children); Frontal (in adults). * **Red Flags:** Proptosis, ophthalmoplegia (restricted eye movement), and decreased visual acuity indicate a transition from preseptal to orbital involvement, necessitating urgent imaging.

Question 50: A child presents with an expansile swelling on the medial side of the nose. What is the likely diagnosis?

A. Teratoma
B. Meningocele (Correct Answer)
C. Dermoid cyst
D. Lipoma

Explanation: **Explanation:** The clinical presentation of an **expansile swelling on the medial side of the nose** in a child is a classic description of a **Meningocele** (or Encephalocele). These are congenital herniations of cranial contents through a defect in the skull base, most commonly occurring at the **foramen caecum**. **Why Meningocele is correct:** Nasal encephaloceles/meningoceles are typically located at the bridge of the nose, often appearing as a bluish, pulsatile, and compressible mass on the medial aspect of the orbit or the nasal dorsum. A key diagnostic feature is the **Furstenberg test**, where compression of the internal jugular vein leads to an increase in the size and tension of the swelling due to increased intracranial pressure. **Why the other options are incorrect:** * **Dermoid Cyst:** While also a common midline nasal mass, it is typically **non-pulsatile** and does not expand with crying or jugular compression (negative Furstenberg test). It often presents with a skin pit or hair follicle. * **Teratoma:** These are rare, complex germ cell tumors. While they can occur in the head and neck (Epignathus), they are usually much larger, more heterogeneous, and present with significant airway obstruction rather than a simple medial nasal swelling. * **Lipoma:** These are soft, fatty tumors that are rare in the pediatric nasal region and do not show the "expansile" characteristics associated with intracranial communication. **High-Yield Clinical Pearls for NEET-PG:** 1. **Never biopsy** a midline nasal mass in a child until an intracranial communication is ruled out via CT/MRI to avoid a CSF leak or meningitis. 2. **Glioma:** A "sequestered" encephalocele that has lost its intracranial connection. It is firm, non-compressible, and does not transilluminate. 3. **Radiology:** MRI is the gold standard to visualize the soft tissue connection to the brain; CT is best for evaluating the bony defect at the skull base.

Practice by Chapter

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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 Tracheostomy

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