Pediatric Head and Neck Masses — MCQs
Which among the following is the commonest malignancy of childhood?
A 23-year-old male patient presents with midline swelling in the neck. The swelling moves with deglutition and protrusion of the tongue. What is the likely diagnosis?
N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:
Which of the following statements about acute retropharyngeal abscess is true?
Juvenile nasopharyngeal angiofibroma spreading to pterygomaxillary fossa is which stage?
A 5-year-old child was admitted to the hospital for a prolapsing rectal mass and painless rectal bleeding. Histopathological examination reveals enlarged and inflamed glands filled with mucin. What is the likely diagnosis?
According to the Lund and Browder chart, what percentage of total body surface area (TBSA) does the head and face represent in a 1-year-old child?
A patient with jaundice is found to have a pancreatic head mass. What is the best diagnostic test?
A 33-year-old male presents with complaints of pain in the left hip. On examination, there is flexion and external rotation of the left lower limb, with a 7 cm shortening of the left lower limb. A gluteal mass is palpable, which moves with the movement of the femoral shaft. What is the most probable diagnosis?
What is the immediate management of a child with foreign body inhalation?
Pediatric Head and Neck Masses Indian Medical PG Practice Questions and MCQs
Question 1: Which among the following is the commonest malignancy of childhood?
- A. Brain tumor
- B. Neuroblastoma
- C. Lymphoma
- D. Acute Lymphoblastic Leukemia (ALL) (Correct Answer)
Explanation: ***Acute Lymphoblastic Leukemia (ALL)*** - **ALL** accounts for approximately 25% of all childhood cancers and is the **most common leukemia** in children. - It is characterized by the rapid production of immature white blood cells (lymphoblasts) in the bone marrow, leading to symptoms like **fatigue, fever, and easy bruising**. *Brain tumor* - **Brain tumors** are the **second most common malignancy** in childhood, after leukemia. - While significant, they are not as frequent as ALL in the overall pediatric cancer population. *Neuroblastoma* - **Neuroblastoma** is a cancer of the nerve cells and is one of the most common cancers in **infants** and **young children (under age 5)**. - It arises from **neuroblasts** (immature nerve cells) and often presents as an abdominal mass, but its overall incidence is lower than ALL. *Lymphoma* - **Lymphomas**, including Hodgkin and non-Hodgkin types, are cancers of the lymphatic system and are significant but **less common than ALL** in childhood. - Non-Hodgkin lymphoma is more common in childhood than Hodgkin lymphoma, but both together are still outranked by leukemia.
Question 2: A 23-year-old male patient presents with midline swelling in the neck. The swelling moves with deglutition and protrusion of the tongue. What is the likely diagnosis?
- A. Brachial cyst
- B. Thyroglossal cyst (Correct Answer)
- C. Plunging ranula
- D. Dermoid cyst
Explanation: ***Thyroglossal cyst*** - A **thyroglossal cyst** is a congenital anomaly that arises from the persistent **thyroglossal duct**, a remnant of the thyroid's embryologic descent. - Its classic diagnostic feature is its movement with **deglutition** (due to attachment to the hyoid bone, which moves during swallowing) and **protrusion of the tongue** (as the thyroglossal duct is connected to the base of the tongue). *Brachial cyst* - A **brachial cyst** is a congenital neck mass that typically presents as a lateral neck swelling, often located along the anterior border of the **sternocleidomastoid muscle**. - Unlike a thyroglossal cyst, it does not typically move with **deglutition** or **tongue protrusion**. *Plunging ranula* - A **plunging ranula** is a type of mucocele that arises from the **sublingual gland** and extends below the mylohyoid muscle into the neck. - It presents as a cervical mass but is typically located in the floor of the mouth or submandibular region and does not move with **deglutition** or **tongue protrusion**. *Dermoid cyst* - A **dermoid cyst** is a congenital cyst that can occur anywhere on the body, including the head and neck, often presenting as a painless mass. - It arises from sequestered embryonic ectoderm and mesoderm, containing skin appendages, but it does not move with **deglutition** or **tongue protrusion**.
Question 3: N3a TNM staging of head and neck tumors (AJCC 8th edition) shows:
- A. Metastasis in a lymph node >6 cm (Correct Answer)
- B. Metastasis in lymph nodes >2 cm
- C. Metastasis in lymph nodes >5 cm
- D. None of the options
Explanation: ***Metastasis in a lymph node >6 cm*** - **N3a disease** in head and neck cancer staging (AJCC 8th edition) specifically refers to metastasis in a single lymph node larger than 6 cm in greatest dimension **without extranodal extension (ENE)**. - This applies to oral cavity, oropharynx (HPV-negative), hypopharynx, and larynx cancers. - **Note:** N3 staging also includes **N3b** (metastasis in any node with clinically overt ENE), but this question specifically asks about N3a criteria. *Metastasis in lymph nodes >2 cm* - Lymph nodes in the 2-3 cm range typically fall within **N1 or N2a categories**, depending on laterality and number of involved nodes. - **N3a disease** requires a single lymph node to exceed 6 cm in greatest dimension without ENE. *Metastasis in lymph nodes >5 cm* - A lymph node between 3-6 cm is usually classified as **N2 disease** (N2a if single ipsilateral ≤6 cm, N2b if multiple ipsilateral ≤6 cm, N2c if bilateral or contralateral ≤6 cm). - To be classified as **N3a**, the lymph node must be **>6 cm** without extranodal extension. *None of the options* - This option is incorrect because the first option accurately describes the size criterion for **N3a TNM staging** in head and neck tumors according to AJCC 8th edition guidelines. - While N3 staging has two subcategories (N3a and N3b), the size criterion of >6 cm correctly defines N3a disease.
Question 4: Which of the following statements about acute retropharyngeal abscess is true?
- A. Treatment often involves incision and drainage.
- B. Acute retropharyngeal abscess is common in adults.
- C. Swelling typically occurs unilaterally.
- D. Acute retropharyngeal abscess is often due to lymphadenitis. (Correct Answer)
Explanation: ***Acute retropharyngeal abscess is often due to lymphadenitis.*** - The **retropharyngeal lymph nodes** (nodes of Rouviere) are prominent in children and drain the nasopharynx, oropharynx, and paranasal sinuses. Infection in these areas can lead to **suppurative lymphadenitis**, which can then progress to an abscess. - **Lymphadenitis** following an upper respiratory tract infection is the **most common etiology** in children, who represent the majority of cases. This is a characteristic pathophysiological mechanism specific to retropharyngeal abscesses. - While other causes exist (trauma, foreign bodies, odontogenic infections in adults), this statement best captures the typical presentation and etiology. *Acute retropharyngeal abscess is common in adults.* - **Retropharyngeal abscesses** are far more common in **children**, especially those under 6 years of age, due to the presence of prominent retropharyngeal lymph nodes that typically atrophy by age 5-6. - In adults, retropharyngeal abscesses are rarer and usually result from trauma, foreign bodies, or odontogenic infections rather than lymphadenitis. *Swelling typically occurs unilaterally.* - The **retropharyngeal space** is a **midline structure**, and infection typically causes **bilateral** or central swelling. - **Edema and inflammation** affect the entire space, leading to generalized posterior pharyngeal wall bulging rather than true unilateral presentation. - While some asymmetry may be visible, describing the swelling as "typically unilateral" is inaccurate. *Treatment often involves incision and drainage.* - While this statement is technically true for **mature abscesses**, it is **incomplete** as a characterizing statement about retropharyngeal abscesses. - Treatment depends on stage: **early phlegmon or cellulitis** may respond to **intravenous antibiotics alone**, while a **mature abscess** requires both **I&D and antibiotics**. - The statement lacks the important context that **antibiotics are the cornerstone** of treatment, with surgical drainage reserved for established abscesses. - This is a treatment modality rather than a defining characteristic of the condition, making it a less complete answer than the etiology-based statement.
Question 5: Juvenile nasopharyngeal angiofibroma spreading to pterygomaxillary fossa is which stage?
- A. Stage IV
- B. Stage III
- C. Stage II (Correct Answer)
- D. Stage I
Explanation: ***Stage II*** - This stage describes **tumor extension** to the **pterygomaxillary fossa** or maxillary, ethmoid, or sphenoid sinuses with bone destruction. - According to the **Fisch staging system** (most widely used), pterygomaxillary fossa involvement specifically defines Stage II disease. - This represents locally advanced disease beyond the nasopharynx but without infratemporal fossa or intracranial extension. *Stage III* - This stage signifies extension to the **infratemporal fossa**, **orbit**, or **parasellar region** (remaining lateral to cavernous sinus). - It represents more extensive local spread than pterygomaxillary fossa involvement alone. - Requires more complex surgical approaches and has greater morbidity. *Stage IV* - This stage indicates **intracranial extension** with involvement of the **cavernous sinus**, **optic chiasm**, or **pituitary fossa**. - It represents the most advanced disease with the highest surgical complexity and potential for complications. - Often requires combined neurosurgical approaches. *Stage I* - Stage I describes a tumor strictly confined to the **nasopharynx** and **nasal cavity** without extension to adjacent structures. - This is the earliest stage with the best prognosis and typically amenable to endoscopic resection. - No bone destruction or extension to sinuses or fossae.
Question 6: A 5-year-old child was admitted to the hospital for a prolapsing rectal mass and painless rectal bleeding. Histopathological examination reveals enlarged and inflamed glands filled with mucin. What is the likely diagnosis?
- A. Adenoma (precancerous lesion in adults)
- B. Juvenile polyp (Hamartoma) (Correct Answer)
- C. Carcinoma (malignant tumor, rare in children)
- D. Choristoma (benign growth of normal tissue in an abnormal location)
Explanation: ***Juvenile polyp (Hamartoma)*** - **Juvenile polyps** are the most common cause of rectal bleeding in children, often presenting as a **prolapsing rectal mass** and **painless bleeding**. - Histologically, they are characterized by **enlarged, inflamed glands filled with mucin**, consistent with a hamartomatous origin. *Adenoma (precancerous lesion in adults)* - While adenomas can cause rectal bleeding and prolapse, they are typically found in **adults** and are considered **precancerous lesions** [1]. - The patient's young age (5-year-old) makes an adenoma highly unlikely [1]. *Carcinoma (malignant tumor, rare in children)* - **Colorectal carcinoma** is exceedingly **rare in children** and usually presents with more aggressive symptoms than painless bleeding, such as weight loss or anemia [2]. - The histological description of inflamed, mucin-filled glands is not typical for carcinoma [2]. *Choristoma (benign growth of normal tissue in an abnormal location)* - A **choristoma** is a benign growth of normal tissue in an abnormal location, but it does not typically present as a rectal mass or cause rectal bleeding. - The microscopic findings of enlarged and inflamed glands filled with mucin are not characteristic of a choristoma. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 371-372. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 821-822.
Question 7: According to the Lund and Browder chart, what percentage of total body surface area (TBSA) does the head and face represent in a 1-year-old child?
- A. 16%
- B. 10%
- C. 19% (Correct Answer)
- D. 13%
Explanation: ***19%*** - The **Lund and Browder chart** accounts for age-related variations in body proportions, assigning a larger percentage of **total body surface area (TBSA)** to the head in infants and young children. - For a **1-year-old child**, the head and face are estimated to represent approximately **19% TBSA**, which decreases with age as the body proportions change. *16%* - While 16% is a value sometimes associated with the head, it is not the accurate percentage for a **1-year-old child** according to the **Lund and Browder chart**. - This percentage is typically closer to that of an **older child** or adult's head, as body proportions change over time. *10%* - **10% TBSA** is far too low for the head and face of a **1-year-old child** as per the Lund and Browder chart. - This value is usually associated with areas like the **arms** in children or the head of an **adult** in some simpler TBSA estimation methods. *13%* - **13% TBSA** is an underestimation for the head and face of a **1-year-old child** when using the **Lund and Browder chart**. - The large relative size of an infant's head means it contributes a significantly higher percentage to their **total body surface area**.
Question 8: A patient with jaundice is found to have a pancreatic head mass. What is the best diagnostic test?
- A. CT scan (Correct Answer)
- B. ERCP
- C. Ultrasound
- D. MRI
Explanation: ***CT scan*** - A **CT scan of the abdomen with contrast** is the initial investigation of choice for suspected pancreatic head mass due to its high diagnostic accuracy [1]. It provides detailed images of the pancreas, surrounding structures, and can help stage the disease [1]. - It effectively visualizes the **mass, evaluates for vascular invasion, and detects metastatic disease**, which are crucial for treatment planning [1]. *ERCP* - **Endoscopic retrograde cholangiopancreatography (ERCP)** is a therapeutic procedure primarily used for bile duct decompression, particularly in cases of obstructive jaundice [2]. - While it can visualize the bile ducts and pancreatic duct, it is **invasive** and not typically used as the primary diagnostic imaging modality for a pancreatic mass itself. *Ultrasound* - **Abdominal ultrasound** can detect a mass and dilated bile ducts, but it is operator-dependent and often has **limited sensitivity** for small pancreatic lesions, particularly in obese patients or those with bowel gas [1]. - It is often used as a first-line screening tool for jaundice but is usually followed by more definitive imaging like CT or MRI due to its **limited detail and penetration**. *MRI* - **Magnetic Resonance Imaging (MRI) with MRCP (Magnetic Resonance Cholangiopancreatography)** provides excellent soft tissue contrast, especially for assessing bile duct obstruction and assessing for vascular invasion [1]. - While highly sensitive, it is **more expensive and less readily available** than CT, making CT the preferred initial diagnostic test.
Question 9: A 33-year-old male presents with complaints of pain in the left hip. On examination, there is flexion and external rotation of the left lower limb, with a 7 cm shortening of the left lower limb. A gluteal mass is palpable, which moves with the movement of the femoral shaft. What is the most probable diagnosis?
- A. Anterior dislocation of hip
- B. Central fracture dislocation
- C. Posterior dislocation
- D. Pipkin's type 4 fracture (Correct Answer)
Explanation: ***Pipkin's type 4 fracture*** - This fracture involves a **femoral head fracture** combined with a **hip dislocation**. The described findings of flexion, external rotation, shortening, and a palpable gluteal mass, which moves with the femoral shaft, are classic signs of a **femoral head fracture-dislocation**, often categorized as a Pipkin type. - The gluteal mass moving with the femoral shaft indicates that the **femoral head** is displaced and can be palpated, which is consistent with a **femoral head fracture** that has dislocated. *Anterior dislocation of hip* - An **anterior hip dislocation** typically presents with the limb in **flexion, abduction, and external rotation**, but it usually involves lengthening rather than shortening due to the head being displaced anteriorly. - There would typically not be a palpable gluteal mass, and the degree of shortening described (7 cm) is more consistent with a complex injury like a fracture-dislocation. *Central fracture dislocation* - A **central fracture dislocation** involves the femoral head pushing through the **acetabulum into the pelvis**. This usually presents with a **shortened and internally rotated limb**, and pain, but not typically a palpable gluteal mass or the specific flexion and external rotation described. - While there is shortening, the mechanism of injury and the palpable mass are not consistent with the femoral head being displaced into the pelvic cavity. *Posterior dislocation* - A **posterior hip dislocation** presents with the limb in **flexion, adduction, and internal rotation**, often with significant shortening. - Although it causes shortening, the patient presents with **external rotation**, not internal rotation, differentiating it from a posterior dislocation. The palpable gluteal mass is also not a typical finding in a pure posterior dislocation without an associated fracture.
Question 10: What is the immediate management of a child with foreign body inhalation?
- A. Intermittent Positive Pressure Ventilation (IPPV)
- B. Bronchoscopy (Correct Answer)
- C. Tracheostomy
- D. Exploratory Thoracotomy
Explanation: **Explanation:** **Foreign body (FB) inhalation** is a life-threatening emergency in the pediatric population, most commonly occurring in children aged 1–3 years. 1. **Why Bronchoscopy is the Correct Answer:** Rigid bronchoscopy is the **gold standard** for both the diagnosis and management of inhaled foreign bodies. It allows for direct visualization of the airway, provides a secure channel for ventilation, and facilitates the use of specialized forceps to grasp and remove the object. In an emergency setting, removing the obstruction is the definitive step to restore airway patency. 2. **Why Other Options are Incorrect:** * **IPPV (A):** Positive pressure ventilation is contraindicated if a foreign body is partially obstructing the airway, as it can push the object deeper into the distal tracheobronchial tree, leading to a complete "ball-valve" obstruction or total lung collapse. * **Tracheostomy (C):** This is indicated for upper airway obstructions (at or above the larynx). Since most inhaled foreign bodies lodge in the main bronchi (right more commonly than left), a tracheostomy would not bypass the obstruction. * **Exploratory Thoracotomy (D):** This is a major surgical procedure reserved only for rare cases where endoscopic removal fails or if the foreign body has caused severe vascular injury or irreversible lung damage. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Site:** Right main bronchus (due to it being wider, shorter, and more vertical than the left). * **Classic Triad:** Sudden onset of coughing, wheezing, and diminished breath sounds. * **Radiology:** The most common finding is **obstructive emphysema** (air trapping) on expiratory films. Radio-opaque objects are seen in only ~10-15% of cases. * **Vegetable FB:** Peanuts are the most common; they cause a severe inflammatory reaction known as **vegetal bronchitis**.
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