Pediatric Otolaryngology — MCQs

Pediatric Otolaryngology Indian Medical PG Practice Questions and MCQs

Question 61: A 7-month-old infant presents with stridor since the tenth day of life. What is the most likely cause?

A. Laryngotracheobronchitis
B. Tracheoesophageal fistula
C. Laryngomalacia (Correct Answer)
D. Eventration of the diaphragm

Explanation: **Explanation:** **Laryngomalacia** is the most common cause of congenital stridor and the most common congenital anomaly of the larynx. It is characterized by an inward collapse of the supraglottic structures (epiglottis, arytenoids) during inspiration due to neuromuscular immaturity or structural flaccidity. * **Clinical Presentation:** Stridor typically appears within the first **2 weeks of life**. It is characteristically **inspiratory**, high-pitched, and worsens when the infant is supine, crying, or feeding, but improves when the infant is prone. * **Diagnosis:** Confirmed by flexible fiberoptic laryngoscopy showing "omega-shaped" epiglottis and short aryepiglottic folds. **Analysis of Incorrect Options:** * **Laryngotracheobronchitis (Croup):** This is an acute viral infection typically seen in older infants (6 months to 3 years). It presents with a sudden onset of barking cough and fever, not a chronic stridor starting from the first weeks of life. * **Tracheoesophageal Fistula (TEF):** This presents primarily with feeding difficulties, choking, cyanosis, and aspiration pneumonia immediately after birth, rather than isolated stridor. * **Eventration of the Diaphragm:** This is a respiratory distress issue caused by the elevation of the diaphragm into the thorax. It presents with tachypnea and decreased breath sounds, not laryngeal stridor. **High-Yield Clinical Pearls for NEET-PG:** * **Management:** 90% of cases resolve spontaneously by 18–24 months. Surgical intervention (**Supraglottoplasty**) is reserved for severe cases with failure to thrive or cor pulmonale. * **Key Sign:** Inspiratory stridor that improves in the **prone position**. * **Associated Condition:** Gastroesophageal reflux (GERD) is frequently associated and can worsen the symptoms.

Question 62: What is the most common cause of recurrent sinusitis in a 5-year-old child?

A. Adenoid hypertrophy (Correct Answer)
B. Angiofibroma
C. Nasal carcinoma
D. All of the above

Explanation: **Explanation:** **1. Why Adenoid Hypertrophy is Correct:** In the pediatric population, **adenoid hypertrophy** is the most common cause of recurrent rhinosinusitis. The adenoids are a collection of lymphoid tissue in the nasopharynx. When enlarged, they act as a **mechanical obstruction** to the choanae, preventing normal mucociliary clearance from the paranasal sinuses. Furthermore, the adenoids serve as a **reservoir (biofilm)** for pathogenic bacteria (such as *H. influenzae* and *S. pneumoniae*), leading to chronic infection and retrograde spread to the sinuses and middle ear. **2. Why Other Options are Incorrect:** * **B. Angiofibroma (Juvenile Nasopharyngeal Angiofibroma):** While it causes nasal obstruction, it typically presents in **adolescent males** (pubertal age) with profuse, spontaneous epistaxis. It is rare in a 5-year-old and is a benign tumor, not a primary cause of recurrent infection. * **C. Nasal Carcinoma:** Malignancies of the nasopharynx or nasal cavity are extremely rare in the pediatric age group. They usually present with cranial nerve palsies or cervical lymphadenopathy rather than simple recurrent sinusitis. * **D. All of the above:** Incorrect, as the prevalence and clinical presentation of B and C do not match the common epidemiological profile of a 5-year-old. **Clinical Pearls for NEET-PG:** * **Triad of Adenoid Hypertrophy:** Mouth breathing, snoring, and hyponasal speech (rhinolalia clausa). * **Adenoid Facies:** Characterized by an open mouth, elongated face, high-arched palate, and crowded teeth due to chronic mouth breathing. * **Associated Condition:** Always look for **Otitis Media with Effusion (OME)** in children with adenoid hypertrophy due to Eustachian tube dysfunction. * **Investigation of Choice:** X-ray Nasopharynx (Lateral view) shows narrowing of the nasopharyngeal airway.

Question 63: All of the following are features of Treacher Collins syndrome, except?

A. Anti-mongoloid palpebral fissure
B. Hypoplasia of malar bones and mandible
C. Macrostomia, high palate
D. Osteomas of bone (Correct Answer)

Explanation: **Explanation:** Treacher Collins Syndrome (TCS), also known as **Mandibulofacial Dysostosis**, is an autosomal dominant disorder caused by mutations in the *TCOF1* gene (encoding the protein Treacle), which affects the development of the first and second branchial arches. **Why Option D is the correct answer:** **Osteomas of the bone** are not a feature of Treacher Collins Syndrome. Instead, they are a hallmark of **Gardner Syndrome** (a variant of Familial Adenomatous Polyposis). In TCS, the skeletal pathology is characterized by **hypoplasia** (underdevelopment) rather than the formation of benign bony outgrowths (osteomas). **Analysis of Incorrect Options:** * **Option A (Anti-mongoloid slant):** This refers to the downward slanting of the palpebral fissures, a classic diagnostic feature of TCS caused by the lack of support from the underlying malar bones. * **Option B (Hypoplasia of malar bones and mandible):** This is the core skeletal defect. Malar hypoplasia leads to depressed cheeks, while mandibular hypoplasia (micrognathia) often results in airway obstruction and dental malocclusion. * **Option C (Macrostomia, high palate):** Due to the failure of proper fusion and development of facial structures, patients often present with a wide mouth (macrostomia) and a high-arched or cleft palate. **NEET-PG Clinical Pearls:** * **Ear Findings:** Conductive hearing loss is common due to ossicular malformations and **microtia/anotia**. * **Coloboma:** Look for a notch in the outer third of the lower eyelid (Coloboma), which is highly characteristic. * **Intelligence:** Unlike many other syndromic craniofacial disorders, intelligence in TCS patients is usually **normal**. * **Inheritance:** Autosomal Dominant (most common) or Autosomal Recessive.

Question 64: In a patient with hypertrophied adenoids, what voice abnormality is typically observed?

A. Rhinolalia clausa (Correct Answer)
B. Rhinolalia aperta
C. Hot potato voice
D. Scatacto voice

Explanation: ### Explanation **Correct Answer: A. Rhinolalia clausa** **Medical Concept:** Adenoids are a collection of lymphoid tissue located in the **nasopharynx**. When they become hypertrophied, they physically obstruct the posterior choanae (the back of the nasal cavity). In normal speech, nasal consonants like /m/, /n/, and /ng/ require air to pass through the nose. In adenoid hypertrophy, this nasal resonance is lost because the airway is blocked. This condition is known as **Hyponasality** or **Rhinolalia clausa** (closed nasality). The patient sounds as if they have a "stuffy nose," and "common" may sound like "cobbo." **Analysis of Incorrect Options:** * **B. Rhinolalia aperta:** Also known as hypernasality. This occurs when the nasopharynx fails to close during speech (e.g., **Cleft Palate** or Velopharyngeal insufficiency), allowing too much air to escape through the nose. * **C. Hot potato voice:** This is a thick, muffled voice characteristic of **Peritonsillar abscess (Quinsy)**. It occurs due to pain and edema causing restricted movement of the soft palate and pharyngeal muscles. * **D. Scatacto voice:** (Often a distractor for "Staccato voice"). A staccato or scanning speech is typically associated with **Cerebellar lesions** (e.g., Multiple Sclerosis), not anatomical obstructions in the throat. **High-Yield Clinical Pearls for NEET-PG:** * **Adenoid Facies:** Characterized by an open mouth, dull expression, elongated face, high arched palate, and crowded teeth due to chronic mouth breathing. * **Ear Complications:** Adenoid hypertrophy is the most common cause of **Otitis Media with Effusion (Glue Ear)** in children due to Eustachian tube obstruction. * **Investigation of Choice:** X-ray Nasopharynx (Lateral view) shows soft tissue mass narrowing the nasopharyngeal airway. * **Gold Standard Diagnosis:** Diagnostic Nasal Endoscopy (DNE).

Question 65: Congenital laryngeal stridor is also known as which of the following?

A. Laryngeal web
B. Laryngomalacia (Correct Answer)
C. Laryngeal atresia
D. Vocal cord palsy

Explanation: **Explanation:** **Laryngomalacia** is the most common cause of congenital stridor in neonates and infants. It is characterized by an inward collapse of the supraglottic structures (epiglottis, aryepiglottic folds, and arytenoids) during inspiration due to abnormal flaccidity of the laryngeal cartilages. Because it is the primary cause of stridor present at or shortly after birth, it is clinically synonymous with the term **Congenital Laryngeal Stridor**. **Analysis of Options:** * **Laryngomalacia (Correct):** The stridor is typically **inspiratory**, high-pitched, and worsens when the infant is supine, crying, or feeding. It usually improves when the infant is prone. * **Laryngeal Web:** This is a rare congenital anomaly caused by the failure of recanalization of the larynx. It typically presents with a weak cry or aphonia and biphasic stridor, rather than simple inspiratory stridor. * **Laryngeal Atresia:** This is a life-threatening emergency present at birth (often part of the CHAOS sequence). It results in complete airway obstruction and is incompatible with life unless an immediate tracheostomy or EXIT procedure is performed. * **Vocal Cord Palsy:** The second most common cause of congenital stridor. If bilateral, it presents with severe respiratory distress; if unilateral, it often presents with a weak cry rather than classic "congenital laryngeal stridor." **High-Yield Clinical Pearls for NEET-PG:** * **Omega-shaped epiglottis:** The classic endoscopic finding in laryngomalacia. * **Diagnosis:** Confirmed by **flexible fiberoptic laryngoscopy** (shows collapse of supraglottic structures on inspiration). * **Management:** Most cases (90%) are self-limiting and resolve by 18–24 months. Severe cases (causing failure to thrive or cor pulmonale) require **supraglottoplasty**.

Question 66: Which of the following is NOT a feature of Treacher-Collins syndrome?

A. Deafness
B. Colobomas of lower eyelid
C. Hypoplasia of zygomatic bone
D. Mongoloid slant of palpebral fissure (Correct Answer)

Explanation: **Explanation:** Treacher-Collins Syndrome (Mandibulofacial Dysostosis) is an autosomal dominant disorder caused by mutations in the **TCOF1 gene**, affecting the development of the first and second branchial arches. **Why Option D is the correct answer:** Treacher-Collins syndrome is characterized by an **Anti-mongoloid slant** (downward slanting) of the palpebral fissures. A "Mongoloid slant" refers to an upward slant (common in Down Syndrome), which is the opposite of the clinical presentation in this condition. **Analysis of other options:** * **A. Deafness:** Conductive hearing loss is a hallmark feature, occurring in about 40-50% of cases due to malformation of the ossicles (malleus and incus) and hypoplasia of the middle ear cavity. * **B. Colobomas of lower eyelid:** This is a classic diagnostic feature. Approximately 75% of patients have a notch (coloboma) in the outer third of the lower eyelid, often associated with a lack of eyelashes in that area. * **C. Hypoplasia of zygomatic bone:** Malar hypoplasia (underdeveloped cheekbones) is a defining skeletal deformity, leading to the characteristic "sunken" appearance of the midface. **High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** Autosomal Dominant (most common) with variable expressivity. * **Key Features:** Micrognathia (small jaw), Fish-like mouth, Choanal atresia, and external ear abnormalities (microtia/anotia). * **Intelligence:** Usually normal, unlike many other syndromic craniofacial disorders. * **Airway:** Difficult intubation is a major anesthetic concern due to severe mandibular hypoplasia.

Question 67: What is the most likely diagnosis in a ten-year-old boy presenting with recurrent epistaxis and a unilateral nasal mass?

A. Antrochoanal polyp
B. Hemangioma
C. Angiofibroma (Correct Answer)
D. Rhinolith

Explanation: **Explanation:** The clinical presentation of a **ten-year-old boy** with **recurrent epistaxis** and a **unilateral nasal mass** is a classic "spotter" for **Juvenile Nasopharyngeal Angiofibroma (JNA)**. **Why Angiofibroma is correct:** JNA is a benign but locally aggressive, highly vascular tumor. It almost exclusively affects **adolescent males** (typically ages 10–20). The hallmark symptoms are painless, progressive unilateral nasal obstruction and profuse, recurrent epistaxis. The tumor typically originates near the sphenopalatine foramen. **Why the other options are incorrect:** * **Antrochoanal Polyp:** While it presents as a unilateral nasal mass in children causing obstruction, it is non-vascular. It does not cause recurrent, profuse epistaxis. * **Hemangioma:** Though vascular, capillary or cavernous hemangiomas usually involve the anterior nasal septum (Little’s area) and are less common as a large obstructing posterior mass in this specific demographic compared to JNA. * **Rhinolith:** This is a "nasal stone" formed by mineral salts around a foreign body. It presents with foul-smelling, purulent unilateral discharge rather than profuse epistaxis. **High-Yield Clinical Pearls for NEET-PG:** * **Holman-Miller Sign (Antral Sign):** Anterior bowing of the posterior wall of the maxillary sinus seen on CT/MRI (Pathognomonic for JNA). * **Diagnosis:** Primarily clinical and radiological. **Biopsy is contraindicated** in the OPD due to the risk of life-threatening hemorrhage. * **Blood Supply:** Most commonly the **Internal Maxillary Artery** (branch of the External Carotid). * **Treatment of Choice:** Surgical excision (often preceded by preoperative embolization to reduce blood loss).

Question 68: What is the most common mode of treatment for laryngomalacia?

A. Reassurance (Correct Answer)
B. Medical management
C. Surgical intervention
D. Observation

Explanation: **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 supraglottic structures (epiglottis, arytenoids) during inspiration. **Why Reassurance is the correct answer:** The vast majority of cases (approximately **90%**) are mild to moderate and follow a self-limiting course. Stridor typically appears at 2 weeks of age, peaks at 6–9 months, and **spontaneously resolves** by 18–24 months as the laryngeal cartilage matures and the airway widens. Therefore, the primary management strategy is parental reassurance and monitoring of growth. **Analysis of Incorrect Options:** * **Medical management (B):** While often used to treat comorbid Gastroesophageal Reflux Disease (GERD) which can exacerbate symptoms, it is not the primary treatment for the structural collapse itself. * **Surgical intervention (C):** Reserved for only **10% of cases** (Severe Laryngomalacia) presenting with "danger signs" such as failure to thrive, cor pulmonale, or life-threatening apnea. The surgery of choice is **Supraglottoplasty**. * **Observation (D):** While clinically similar to reassurance, "Reassurance" is the preferred terminology in exams to emphasize the benign, self-resolving nature of the condition to the caregivers. **High-Yield Clinical Pearls for NEET-PG:** * **Stridor characteristics:** Inspiratory, high-pitched, worsens when supine or crying, improves when prone. * **Omega-shaped epiglottis:** The classic endoscopic finding (due to short aryepiglottic folds). * **Diagnosis:** Confirmed by **Flexible Fiberoptic Laryngoscopy** in an awake, spontaneously breathing infant. * **Synchronous lesions:** 10-15% of patients may have a second airway lesion (e.g., subglottic stenosis).

Question 69: Von Langenbeck repair is used for the treatment of which condition?

A. Cleft lip
B. Cleft palate (Correct Answer)
C. Septal deviation
D. Saddle nose

Explanation: **Explanation:** **Von Langenbeck repair** is one of the oldest and most fundamental surgical techniques used for the management of **Cleft Palate (Option B)**. The procedure is a "bipedicled mucoperiosteal flap" technique. It involves making relaxing incisions (lateral incisions) along the alveolar ridges, elevating the palatal mucoperiosteum from the hard palate, and sliding the flaps medially to close the midline defect. Its primary goal is to close the anatomical gap, though it does not involve muscle repositioning (unlike the Furlow or Wardill-Kilner repairs). **Analysis of Incorrect Options:** * **Cleft Lip (Option A):** This is managed using techniques like the **Millard Rotation-Advancement flap** or the **Tennison-Randall triangular flap**. * **Septal Deviation (Option C):** This is treated via **SMR (Submucous Resection)** or **Septoplasty**. * **Saddle Nose (Option D):** This deformity requires augmentation rhinoplasty using autologous grafts (cartilage/bone) or synthetic implants. **High-Yield Clinical Pearls for NEET-PG:** * **Timing of Surgery:** Cleft lip repair is typically done at **3–6 months** (Rule of 10s), while Cleft palate repair is ideally performed between **6–12 months** to allow for proper speech development. * **Veau’s Classification:** Used to categorize the extent of cleft palate. * **Modified Wardill-Kilner (V-Y Pushback):** A common alternative to Von Langenbeck that aims to lengthen the palate to improve velopharyngeal function. * **Complication:** The most common complication of palatoplasty is the formation of a **palatal fistula**.

Question 70: Which of the following is NOT a feature of the Eustachian tube in children?

A. Wider and shorter
B. Flaccid due to less elastin content
C. Ostmann's pad of fat is more in volume (Correct Answer)
D. Isthmus is straight in children

Explanation: ### Explanation The Eustachian tube (ET) connects the middle ear to the nasopharynx, serving functions of ventilation, protection, and drainage. The anatomical differences between the pediatric and adult ET are high-yield topics for NEET-PG, as they explain why children are more prone to Otitis Media with Effusion (OME). **Why Option C is the Correct Answer:** **Ostmann’s pad of fat** is a collection of adipose tissue located lateral to the membranous wall of the ET. Its primary function is to provide bulk and help keep the tube closed to prevent reflux of nasopharyngeal secretions. In children, this fat pad is **less in volume** compared to adults. The reduced volume contributes to a more "patulous" or easily opened tube, facilitating the entry of pathogens into the middle ear. **Analysis of Incorrect Options:** * **Option A (Wider and shorter):** This is a classic feature. The pediatric ET is approximately 18 mm long (half the adult length of 36 mm) and has a wider lumen, making it easier for infections to ascend. * **Option B (Flaccid due to less elastin):** The cartilage in a child’s ET is more compliant and contains less elastin. This flaccidity leads to poor active opening (dilatory dysfunction) and increased risk of collapse. * **Option D (Isthmus is straight):** In adults, the ET is angulated (approx. 45°), whereas in children, it is more **horizontal (approx. 10°)** and the isthmus is relatively straight. This lack of angulation removes the natural gravity barrier against reflux. **High-Yield Clinical Pearls for NEET-PG:** 1. **Angle of ET:** 10° in infants vs. 45° in adults. 2. **Length of ET:** 18 mm at birth vs. 36 mm in adults. 3. **Tensor Veli Palatini:** This is the primary muscle responsible for opening the ET. In children, it is less efficient due to the horizontal orientation of the tube. 4. **Adenoid Hypertrophy:** The most common cause of mechanical ET obstruction in children.

Practice by Chapter

Congenital Anomalies of the Ear

Practice Questions

Pediatric Hearing Loss

Practice Questions

Otitis Media in Children

Practice Questions

Pediatric Sinusitis

Practice Questions

Pediatric Sleep Apnea

Practice Questions

Stridor in Children

Practice Questions

Congenital Airway Anomalies

Practice Questions

Foreign Body Management

Practice Questions

Pediatric Head and Neck Masses

Practice Questions

Pediatric Tracheostomy

Practice Questions

Pediatric Voice Disorders

Practice Questions

Pierre Robin Sequence and Airway Management

Practice Questions

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