Pediatric Tracheostomy — MCQs
Which of the following statements about the upper airways of a neonate is true?
Which of the following is characteristic of emergency tracheostomy?
One of the most important complication of tracheostomy is:
A tracheostomised patient, with Portex tracheostomy tube, in the ward, developed sudden complete blockage of the tube. Which of the following is the best next step in the management -
High tracheostomy is done in:-
A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
High tracheostomy is done in which one of the following conditions?
A boy has developed epistaxis. What is the treatment of choice?
What is the immediate management of a child with foreign body inhalation?
All are seen in Treacher Collins syndrome except?
Pediatric Tracheostomy Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following statements about the upper airways of a neonate is true?
- A. The larynx extends from C1 to C3.
- B. The epiglottis is large and omega-shaped. (Correct Answer)
- C. More than one of the above statements is true.
- D. The cricoid cartilage is the narrowest part of the airway in neonates.
Explanation: ***The epiglottis is large and omega-shaped.*** - In neonates, the **epiglottis** is relatively **large**, U-shaped or **omega-shaped**, and floppy - This anatomical feature can contribute to airway obstruction due to its proximity to the soft palate - This anatomical difference from adults has important implications for **intubation and airway management**, as it makes visualizing the vocal cords more challenging - **This is the correct statement** about neonatal upper airway anatomy *The larynx extends from C1 to C3.* - The **larynx of a neonate** is located more **superiorly** and anteriorly compared to an adult, generally extending from **C3 to C4** (NOT C1 to C3) - Its higher position contributes to the neonate's obligate **nasal breathing** and makes the airway more susceptible to obstruction - The stated vertebral level (C1-C3) is **incorrect** *The cricoid cartilage is the narrowest part of the airway in neonates.* - **Historically**, the **cricoid cartilage** was considered the narrowest part of the pediatric airway, and this remains in many older textbooks - **Recent evidence** suggests that the **rima glottidis** (at the level of the vocal cords) is actually the narrowest point in most neonates and children - This evolving understanding has implications for **tube sizing** and airway management in pediatric patients - Based on current anatomical evidence, this statement is considered **incorrect** *More than one of the above statements is true.* - As only **one statement** is anatomically correct regarding the neonate's upper airway (the omega-shaped epiglottis), this option is **incorrect** - The detailed anatomical differences, such as the position of the larynx and the shape of the epiglottis, are crucial for understanding neonatal airway physiology
Question 2: Which of the following is characteristic of emergency tracheostomy?
- A. Horizontal skin incision
- B. Is well planned and prepared
- C. Cosmetically better
- D. Vertical incision (Correct Answer)
Explanation: ***Vertical incision*** - An emergency tracheostomy typically uses a **vertical skin incision** to expedite airway access, as precision and cosmetic outcomes are secondary to speed in a life-threatening situation. - This approach minimizes time spent dissecting through tissue layers, crucial when rapid airway establishment is needed. *Horizontal skin incision* - A **horizontal skin incision** is usually preferred for **elective tracheostomies** due to its cosmetic benefits, as it can be hidden within skin creases. - This incision allows for a more meticulous dissection of the soft tissues and strap muscles, which is not feasible in an emergency. *Is well planned and prepared* - **Emergency tracheostomy** is by definition an unplanned procedure, performed when other airway management techniques have failed or are not possible. - It is typically carried out under urgent circumstances with limited preparation, often at the bedside or in an emergency setting. *Cosmetically better* - A vertical incision, while quicker in an emergency, generally results in a **less cosmetically appealing scar** compared to a horizontal incision. - Cosmetic considerations are secondary to establishing an airway in an emergency, meaning **scar formation** is not prioritized.
Question 3: One of the most important complication of tracheostomy is:
- A. Hemorrhage
- B. Surgical emphysema
- C. Displacement of tube (Correct Answer)
- D. Recurrent laryngeal nerve palsy
Explanation: ***Displacement of tube*** - **Accidental decannulation** or displacement of the tracheostomy tube is considered one of the most serious and common complications, particularly in the immediate post-operative period. - This can lead to **loss of airway**, requiring immediate intervention to prevent severe hypoxia and potential brain injury or death. *Hemorrhage* - While hemorrhage can occur during or after tracheostomy, it is often a concern during the procedure or in the immediate postoperative period and is usually managed effectively. - Significant, life-threatening hemorrhage such as **tracheo-innominate fistula** is a rare but severe complication. *Surgical emphysema* - Surgical emphysema (subcutaneous emphysema) is a relatively common but usually benign complication that occurs when air leaks from the trachea into the subcutaneous tissues. - It typically resolves spontaneously and rarely poses a direct threat to the airway unless severe and rapidly progressive. *Recurrent laryngeal nerve palsy* - **Recurrent laryngeal nerve injury** is a rare complication of tracheostomy, as the nerve is usually well clear of the incision site in the neck. - While it can cause hoarseness or vocal cord paralysis, it typically does not present an immediate life-threatening situation or emergency comparable to airway compromise.
Question 4: A tracheostomised patient, with Portex tracheostomy tube, in the ward, developed sudden complete blockage of the tube. Which of the following is the best next step in the management -
- A. Suction of tube with saline
- B. Suction of tube with sodium bicarbonate
- C. Jet ventilation
- D. Immediate removal of the tracheostomy tube (Correct Answer)
Explanation: ***Immediate removal of the tracheostomy tube*** - In cases of **sudden complete tracheostomy tube blockage**, the primary concern is airway patency. Removing the tube is the quickest way to re-establish an airway, as the **tracheostomy stoma** will likely provide a path for breathing. - Delaying removal for suctioning or other interventions can lead to **critical hypoxia** and respiratory arrest if the blockage is total. *Suction of tube with saline* - While suctioning is a routine part of tracheostomy care, using saline to clear a **completely blocked tube** is unlikely to be effective and will delay definitive airway management. - The blockage, if complete and sudden, suggests a solid or highly viscous obstruction that saline alone cannot quickly resolve, potentially worsening the situation by pushing the obstruction deeper. *Suction of tube with sodium bicarbonate* - Sodium bicarbonate can be used for mucolytic purposes in some respiratory conditions, but it is not an immediate solution for a **sudden complete airway obstruction**. - Its action is too slow, and attempting to instill it into a completely blocked tube not only wastes critical time but would also be ineffective in rapidly clearing the blockage. *Jet ventilation* - Jet ventilation requires a patent airway for effective gas exchange, which is absent in a **completely blocked tracheostomy tube**. - Attempting **jet ventilation** through a blocked tube or directly into the stoma without first clearing the primary obstruction would be ineffective and could potentially cause **barotrauma**.
Question 5: High tracheostomy is done in:-
- A. Vocal cord palsy
- B. Laryngeal carcinoma (Correct Answer)
- C. Subglottic stenosis
- D. Laryngomalacia
Explanation: ***Laryngeal carcinoma*** - A high tracheostomy, often performed above the second tracheal ring, is indicated in **laryngeal carcinoma** to bypass the obstruction caused by the tumor and ensure a clear airway. - This position provides a more superior opening, which can be crucial when the lower trachea is needed for potential surgical resection or reconstruction, particularly in cases involving extensive laryngeal involvement. *Vocal cord palsy* - **Vocal cord palsy** primarily affects phonation and can cause aspiration, but it typically does not cause acute or severe enough airway obstruction to warrant an emergency tracheostomy. - Airway management for vocal cord palsy often involves voice therapy, glottic augmentation, or arytenoid adduction, rather than high tracheostomy. *Subglottic stenosis* - **Subglottic stenosis** involves narrowing below the vocal cords and usually requires a tracheostomy that is placed **below the level of the stenosis** to bypass the obstruction, often necessitating a low or standard tracheostomy. - A high tracheostomy might be within or too close to the stenotic segment, making it ineffective or surgically challenging. *Laryngomalacia* - **Laryngomalacia** is a congenital condition where the larynx collapses inward during inspiration, causing stridor, most commonly resolving spontaneously by 18-24 months. - Tracheostomy is reserved for severe cases with significant respiratory distress or failure to thrive, and the placement is usually standard or low to ensure bypass of the floppy laryngeal tissues, not typically a high tracheostomy.
Question 6: A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
- A. Acute Laryngotracheobronchitis (Correct Answer)
- B. Acute Bacterial Tracheitis
- C. Acute Epiglottitis
- D. Foreign Body aspiration
Explanation: ***Acute Laryngotracheobronchitis*** - The combination of **low-grade fever** and **stridor** in a 2-year-old child strongly suggests **croup**, which is medically known as acute laryngotracheobronchitis. - Croup is characterized by **inflammation** of the larynx, trachea, and bronchi, often presenting with a **barking cough** and inspiratory stridor. The X-ray image would show the characteristic **steeple sign**. *Acute Bacterial Tracheitis* - This is a more severe bacterial infection that can present with stridor but typically shows **higher fever**, **toxic appearance**, and rapid clinical deterioration. - Unlike croup, bacterial tracheitis patients appear **more ill** and may have **purulent secretions** requiring more aggressive management. *Acute Epiglottitis* - A serious condition characterized by **rapid onset of high fever**, **dysphagia**, drooling, and a **"tripod" position**, which are not indicated by the given symptoms. - The stridor in epiglottitis is typically quieter and may indicate more severe airway obstruction compared to the characteristic stridor of croup. *Foreign Body aspiration* - While foreign body aspiration can cause stridor, it is typically an **acute event** with a sudden onset of choking, coughing, and respiratory distress. - There is no mention of a choking episode or sudden onset, and a low-grade fever is less typical for an uncomplicated foreign body aspiration.
Question 7: High tracheostomy is done in which one of the following conditions?
- A. Laryngeal cancer
- B. Tracheal stenosis (Correct Answer)
- C. Severe asthma exacerbation
- D. Vocal cord dysfunction
Explanation: ***Tracheal stenosis*** - A **high tracheostomy** is performed when there is **lower tracheal stenosis** or obstruction, requiring placement of the tracheostomy stoma **above the stenotic segment**. - This approach ensures that the **tracheostomy tube** bypasses the narrowed portion of the trachea and provides a patent airway. - The level of tracheostomy is chosen based on the location of the pathology - high tracheostomy for lower pathology, and vice versa. *Laryngeal cancer* - In **laryngeal cancer**, a **low tracheostomy** is typically preferred, not a high one. - A high tracheostomy in laryngeal malignancy is generally **contraindicated** due to the risk of tumor seeding and interference with surgical planning. - The tracheostomy should be placed **away from the tumor site** and below the pathology, especially if laryngectomy is planned. *Severe asthma exacerbation* - **Severe asthma exacerbation** rarely requires a tracheostomy; endotracheal intubation and mechanical ventilation are the standard initial management. - If prolonged ventilatory support is needed, a **standard tracheostomy** (not high) would be performed. - There is no specific indication for high tracheostomy placement in asthma. *Vocal cord dysfunction* - **Vocal cord dysfunction (VCD)** involves paradoxical vocal cord movement and is typically managed with **conservative measures** including speech therapy and breathing exercises. - VCD does not cause structural obstruction requiring surgical airway intervention. - Tracheostomy, especially high tracheostomy, has no role in the management of VCD.
Question 8: A boy has developed epistaxis. What is the treatment of choice?
- A. Cauterization of vessels
- B. Surgical ligation
- C. Digital pressure (Correct Answer)
- D. Nasal packing
Explanation: ***Digital pressure*** - This is the **initial and most common first-line treatment** for acute epistaxis, especially in children, as most nosebleeds originate from Kiesselbach's plexus in the anterior septum. - Applying firm, continuous pressure to the soft part of the nose for 10-15 minutes can effectively compress the bleeding vessels and promote clot formation. *Cauterization of vessels* - This method is used when **digital pressure fails** to control the bleeding and the bleeding site can be identified, often in the anterior septum. - It involves using chemical (e.g., silver nitrate) or electrical methods to seal the bleeding vessel. *Surgical ligation* - **Surgical ligation** is reserved for severe, posterior epistaxis that is refractory to other methods like nasal packing or embolization. - It involves surgically tying off the major arteries supplying the nose (e.g., internal maxillary, external carotid) and carries greater risks. *Nasal packing* - **Nasal packing** is typically used when direct pressure has failed, and the bleeding site is not easily amenable to cauterization, or in cases of posterior epistaxis. - It involves inserting material into the nasal cavity to apply direct pressure to the bleeding vessel, but it is more invasive and uncomfortable than digital pressure.
Question 9: 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**.
Question 10: All are seen in Treacher Collins syndrome except?
- A. Conductive deafness
- B. Cleft palate
- C. Mandibular hypoplasia
- D. Choanal atresia (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. It results from the failure of migration of neural crest cells into the **first and second branchial arches**. **Why Choanal Atresia is the Correct Answer:** While TCS involves extensive craniofacial malformations, **Choanal atresia** is not a characteristic feature of this syndrome. Choanal atresia is more classically associated with **CHARGE syndrome** (Coloboma, Heart defects, Atresia choanae, Retardation, Genitourinary anomalies, and Ear abnormalities). **Analysis of Incorrect Options:** * **Conductive Deafness:** This is a hallmark of TCS. It occurs due to malformation of the ossicles (incus and malleus) and/or **meatal atresia** (narrowing or absence of the external auditory canal). * **Cleft Palate:** Approximately 30% of patients with TCS present with a cleft palate, often accompanied by macrostomia (large mouth). * **Mandibular Hypoplasia:** This is a defining feature. Patients exhibit a "bird-like" facies due to micrognathia (small jaw) and malar (cheekbone) hypoplasia. **High-Yield Clinical Pearls for NEET-PG:** * **Antimongoloid slant:** The eyes show a downward slant of the palpebral fissures. * **Coloboma:** Notch-like defects are typically seen in the **outer third of the lower eyelids**. * **Fish-mouth appearance:** Due to the combination of mandibular hypoplasia and macrostomia. * **Inheritance:** Autosomal Dominant (most common) but can be sporadic. * **Inner Ear:** Usually remains normal as it develops from the otic capsule, not the branchial arches.
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