Pediatric Voice Disorders — MCQs
Most common organism causing laryngotracheobronchitis is:
Treatment of choice in early vocal nodule is:
All are true about spasmodic dysphonia EXCEPT:
A 45-year-old patient presents with persistent hoarseness for 3 months. Which finding on indirect laryngoscopy is most concerning for malignancy?
A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
All of the following are correct about the image shown except:
Which of the following statements about laryngomalacia is true?
The following image shows:
What is the immediate management of a child with foreign body inhalation?
All are seen in Treacher Collins syndrome except?
Pediatric Voice Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Most common organism causing laryngotracheobronchitis is:
- A. RSV
- B. Parainfluenzavirus (Correct Answer)
- C. Influenza virus
- D. H. influenzae
Explanation: ***Parainfluenzavirus*** - **Parainfluenza viruses** (PIVs), particularly PIV-1 and PIV-2, are the **most common causes of croup** (laryngotracheobronchitis) in children. - They primarily cause inflammation and swelling of the **larynx, trachea, and bronchi**, leading to the characteristic **barking cough** and stridor. *RSV* - **Respiratory Syncytial Virus (RSV)** is the **most common cause of bronchiolitis** and pneumonia in infants and young children. - While it can cause upper respiratory symptoms, it is less frequently the primary cause of croup compared to parainfluenza viruses. *Influenza virus* - **Influenza virus** typically causes **influenza** (the flu), which presents with more systemic symptoms like high fever, body aches, and fatigue. - Although influenza can lead to severe respiratory complications, it is a less common cause of isolated laryngotracheobronchitis. *H. influenzae* - **_Haemophilus influenzae_** type b (Hib) was historically a major cause of **epiglottitis**, a severe and life-threatening infection of the epiglottis. - With widespread vaccination, Hib infections are rare, and it is not a common cause of laryngotracheobronchitis.
Question 2: Treatment of choice in early vocal nodule is:
- A. Voice rest and speech therapy (Correct Answer)
- B. Cryotherapy
- C. Microlaryngoscopic removal
- D. Radical excision
Explanation: ***Voice rest and speech therapy*** - In cases of **early vocal nodules**, conservative management with **voice rest** and **speech therapy** is the primary treatment. - This approach aims to reduce vocal trauma and modify vocal habits, allowing the nodules to resolve naturally without surgical intervention. *Cryotherapy* - **Cryotherapy** involves freezing and destroying abnormal tissue and is not a standard treatment for vocal nodules. - Its application is more common for superficial lesions, such as certain skin cancers or warts, not benign vocal cord growths. *Microlaryngoscopic removal* - Although **microlaryngoscopic removal** is an option for vocal nodules, it is usually reserved for larger, more established nodules that have not responded to conservative measures. - This is an invasive procedure and is not the **first-line treatment** for early-stage nodules where non-surgical methods are often effective. *Radical excision* - **Radical excision** is a surgical technique for removing lesions, but it is not typically applied to vocal nodules. - The term "radical excision" is often used in the context of oncological procedures involving extensive tissue removal, not benign vocal cord lesions.
Question 3: All are true about spasmodic dysphonia EXCEPT:
- A. Responds well to botulinum toxin
- B. Adductor type is more common
- C. Usually bilateral involvement
- D. More common in children (Correct Answer)
Explanation: ***More common in children*** - Spasmodic dysphonia is primarily a disorder affecting **adults**, with onset typically occurring between the ages of 30 and 50 years. - It is **rarely seen in children**, and when voice disorders occur in children, they are usually due to other causes like vocal nodules or muscle tension dysphonia. *Responds well to botulinum toxin* - **Botulinum toxin (Botox) injections** into the laryngeal muscles are considered the **gold standard treatment** for spasmodic dysphonia. - It effectively paralyzes the spasmodic muscles, providing **significant symptomatic relief** for several months. *Adductor type is more common* - The **adductor type**, characterized by a strained, choked, or squeezed voice quality, accounts for approximately **85-90% of all spasmodic dysphonia cases**. - This is due to involuntary spasms that cause the vocal cords to slam together too tightly. *Usually bilateral involvement* - Spasmodic dysphonia primarily involves the **laryngeal intrinsic muscles**, and the spasms are often **bilateral**, affecting muscles on both sides of the larynx. - While one side might be more affected, the underlying neurological dysfunction typically manifests with **bilateral muscle activation abnormalities**.
Question 4: A 45-year-old patient presents with persistent hoarseness for 3 months. Which finding on indirect laryngoscopy is most concerning for malignancy?
- A. Reinke's edema
- B. Unilateral cord paralysis (Correct Answer)
- C. Bilateral polyps
- D. Vocal cord nodules
Explanation: ***Unilateral cord paralysis*** - **Unilateral cord paralysis** can be an indicator of an underlying malignancy impinging on the **recurrent laryngeal nerve**, which innervates the vocal cords. - The **persistent hoarseness** for 3 months, combined with paralysis, raises significant concern for a malignant process in the head, neck, or chest. *Reinke's edema* - **Reinke's edema** is typically associated with **chronic irritation** like smoking and presents as a swollen, gelatinous fluid collection in the superficial lamina propria. - While it causes hoarseness, it is a **benign condition** and not directly indicative of malignancy. *Bilateral polyps* - **Vocal cord polyps** are typically **benign lesions** often caused by vocal trauma or abuse, and while they can cause hoarseness, they are not usually a direct sign of malignancy, especially when bilateral. - While requiring management, polyps themselves do **not raise immediate concern for cancer** compared to paralysis. *Vocal cord nodules* - **Vocal cord nodules** (singer's nodules) are benign, bilateral lesions caused by **vocal abuse** and are a common cause of hoarseness. - They are a benign condition and do not suggest an underlying malignancy at their core.
Question 5: 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 6: All of the following are correct about the image shown except:
- A. Omega shaped epiglottis
- B. High pitched expiratory stridor (Correct Answer)
- C. Cry is normal
- D. 10% cases need surgery due to development of OSA or Cor Pulmonale
Explanation: ***High pitched expiratory stridor*** - The image depicts an **omega-shaped epiglottis** and collapsed aryepiglottic folds, consistent with **laryngomalacia**. - Laryngomalacia typically presents with **inspiratory stridor**, not expiratory, resulting from airway collapse during inspiration. - **This is the EXCEPT answer** - high-pitched expiratory stridor is NOT a feature of laryngomalacia. *Omega shaped epiglottis* - The image clearly shows an **omega-shaped epiglottis**, a characteristic feature of **laryngomalacia**. - This anatomical variation contributes to the collapse of supraglottic structures during inspiration. *Cry is normal* - In laryngomalacia, the **vocal cords** themselves are not affected, so the **cry typically remains normal**. - The abnormal sounds (stridor) arise from the supraglottic structures, not the vocal cord function during crying. *10% cases need surgery due to development of OSA or Cor Pulmonale* - While most cases of laryngomalacia are self-limiting, approximately **10% of infants may require surgical intervention** (supraglottoplasty). - This is usually due to severe symptoms like **obstructive sleep apnea (OSA)**, failure to thrive, or the rare development of **cor pulmonale**.
Question 7: Which of the following statements about laryngomalacia is true?
- A. It is characterized by an omega-shaped epiglottis.
- B. It requires immediate surgical intervention.
- C. It always requires surgical intervention in newborns.
- D. It typically presents with inspiratory stridor. (Correct Answer)
Explanation: ***It typically presents with inspiratory stridor.*** - **Laryngomalacia** is the most common cause of **inspiratory stridor** in infants, usually presenting within the first few weeks of life due to collapse of supraglottic structures during inspiration. - The stridor is characteristically **worse when crying, feeding, or lying supine**, and often improves when the infant is prone. *It is characterized by an omega-shaped epiglottis.* - While an **omega-shaped epiglottis** can be a feature seen in laryngomalacia, it is not the sole or defining characteristic and is not universally present. - The primary characteristic is the **collapse of the supraglottic structures** (arytenoids, aryepiglottic folds, and epiglottis) into the laryngeal inlet upon inspiration. *It requires immediate surgical intervention.* - The vast majority of **laryngomalacia cases are mild to moderate** and resolve spontaneously by 12-18 months of age, requiring only conservative management. - **Surgical intervention** (supraglottoplasty) is reserved for severe cases with significant feeding difficulties, failure to thrive, severe airway obstruction, or apneic episodes. *It always requires surgical intervention in newborns.* - As mentioned, **most cases are self-limiting** and do not require surgery, especially in newborns. - Surgical intervention is only considered when there are **severe symptoms** impacting the infant's health and development.
Question 8: The following image shows:
- A. Respiratory papillomatosis (Correct Answer)
- B. Vocal nodule
- C. Vocal polyp
- D. TB of vocal cords
Explanation: ***Respiratory papillomatosis*** - The image displays multiple **wart-like growths** on the vocal cords, characteristic of **respiratory papillomatosis**, which is caused by the **human papillomavirus (HPV)**. - These lesions often have an **irregular, cauliflower-like appearance** and can recur even after removal, making it a challenging condition to manage. *Vocal nodule* - Vocal nodules are typically **bilateral, symmetrical lesions** located at the junction of the anterior and middle thirds of the vocal cords. - They are usually **smooth, small, and whitish**, resulting from chronic vocal abuse, unlike the irregular and multiple growths seen in the image. *Vocal polyp* - Vocal polyps are typically **unilateral lesions** that can appear as sessile or pedunculated masses on a vocal cord. - They are often **larger than nodules** and may have a reddish or gelatinous appearance, but they usually occur singly, not as multiple diffuse growths like those pictured. *TB of vocal cords* - Tuberculosis of the vocal cords often presents with **ulcerative lesions**, granulomas, or diffuse inflammation, and may be accompanied by other signs of pulmonary TB. - The lesions caused by TB are generally **not papillomatous** or wart-like in nature, differentiating them from the appearance in the image.
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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