Pediatric Chest Imaging — MCQs
The 'steeple sign' on X-ray neck (as shown in the image) is characteristically seen in which of the following diseases?
A 3-month-old infant with no chest indrawing and a respiratory rate of 52/minute. The diagnosis is:
A child comes with cyanotic spells and chest X-ray was as shown below; What is the most probable diagnosis?
In a child with coarctation of aorta, all the following are seen in plain chest radiograph except:
With reference to Respiratory Distress Syndrome (RDS), which of the following statements is false?
Thumb sign in lateral X-ray of the neck is seen in?
A 3-month-old child presents with indrawing of the chest and a respiratory rate of 52 breaths per minute. This condition can be classified as:
A 10yr old boy with a known case of nephrotic syndrome since 4 years on treatment brought to the pediatric OPD with chief complaint of difficulty in breathing. There is no history of fever. On examination, respiratory system was normal except slightly reduced breath sounds on right infra-axillary region. Paediatrician thinks of pleural effusion. What is next best modality of investigation to detect pleural effusion?
One year old male child with cat's reflex and raised IOP. What is the most likely diagnosis?
Treatment of choice for antrochoanal polyp in a 10-year-old child-
Pediatric Chest Imaging Indian Medical PG Practice Questions and MCQs
Question 1: The 'steeple sign' on X-ray neck (as shown in the image) is characteristically seen in which of the following diseases?
- A. Epiglottitis
- B. Croup (Correct Answer)
- C. Laryngomalacia
- D. Bronchiolitis
Explanation: ***Croup*** - The image suggests a **steeple sign** on the X-ray neck, which corresponds to the subglottic narrowing characteristic of croup. - Croup, primarily caused by **parainfluenza virus**, leads to inflammation and edema below the vocal cords reducing the airway. *Epiglottitis* - Epiglottitis is characterized by a **"thumb sign"** on lateral neck X-ray, indicating a swollen epiglottis. - Patients with epiglottitis typically present with rapidly progressing airway obstruction, high fever, and drooling, unlike the gradual onset and barking cough of croup. *Laryngomalacia* - Laryngomalacia involves the **collapse of supraglottic structures** during inspiration, causing inspiratory stridor. - It would not typically present with the subglottic narrowing seen in the image, but rather with dynamic airway changes visualized during endoscopy. *Bronchiolitis* - Bronchiolitis involves inflammation of the **small airways (bronchioles)** and is usually diagnosed clinically, with chest X-rays showing hyperinflation or peribronchial cuffing if at all. - It primarily affects the lower respiratory tract and would not produce findings like the steeple sign on a neck X-ray.
Question 2: A 3-month-old infant with no chest indrawing and a respiratory rate of 52/minute. The diagnosis is:
- A. Severe pneumonia
- B. Pneumonia (Correct Answer)
- C. No pneumonia
- D. Very severe disease
Explanation: ***Pneumonia*** - A respiratory rate of 52/minute in a 3-month-old infant **meets the age-specific threshold for tachypnea** (respiratory rate ≥ 50 breaths/minute for infants 2-12 months according to IMCI guidelines). - In the **absence of chest indrawing**, the presence of fast breathing (tachypnea) alone classifies this as **pneumonia** per IMCI classification. - This requires **outpatient management with oral antibiotics** and close follow-up. *No pneumonia* - This diagnosis would apply if the respiratory rate was **< 50 breaths/minute** for this age group with no chest indrawing. - Since the respiratory rate is 52/minute (≥ 50/minute), this rules out "no pneumonia." *Severe pneumonia* - This diagnosis requires the presence of **chest indrawing** in addition to fast breathing. - The question explicitly states **"no chest indrawing,"** which excludes severe pneumonia. - Severe pneumonia would require **hospitalization and parenteral antibiotics**. *Very severe disease* - This diagnosis involves **danger signs** such as inability to drink or breastfeed, persistent vomiting, convulsions, lethargy, unconsciousness, or severe malnutrition. - None of these critical signs are mentioned in the clinical scenario. - Very severe disease requires **urgent hospitalization and injectable antibiotics**.
Question 3: A child comes with cyanotic spells and chest X-ray was as shown below; What is the most probable diagnosis?
- A. Tricuspid atresia
- B. Tetralogy of Fallot (Correct Answer)
- C. TAPVC
- D. Pulmonary atresia with intact ventricular septum
Explanation: ***Tetralogy of Fallot*** - The **boot-shaped heart** (Coeur en sabot) seen on the chest X-ray is virtually pathognomonic for **Tetralogy of Fallot** due to right ventricular hypertrophy and a concave pulmonary artery segment. - **Cyanotic spells** (hypercyanotic or "tet" spells) are characteristic clinical features resulting from increased right-to-left shunting across the ventricular septal defect. *Tricuspid atresia* - While tricuspid atresia causes **cyanosis**, the classic radiographic finding is usually a **small right ventricle** and a large left ventricle, affecting heart size and shape differently, often with normal or decreased pulmonary vascularity. - A **boot-shaped heart** is not a typical finding; it might show a normal or slightly enlarged heart with distinct chamber enlargement patterns. *TAPVC* - Total anomalous pulmonary venous connection (TAPVC) typically presents with **cyanosis** and can have increased pulmonary vascular markings on CXR, but the classic X-ray finding is a **"snowman" or "figure-of-8" heart** in the supracardiac type due to dilated SVC and anomalous vertical vein. - A **boot-shaped heart** is not associated with TAPVC. *Pulmonary atresia with intact ventricular septum* - This condition presents with **severe cyanosis** at birth. The chest X-ray typically shows a **markedly enlarged right atrium** due to severe tricuspid regurgitation and a small, hypoplastic right ventricle, along with decreased pulmonary vascular markings. - A **boot-shaped heart** is not a characteristic finding; the cardiac silhouette is often described as globular or enlarged differently.
Question 4: In a child with coarctation of aorta, all the following are seen in plain chest radiograph except:
- A. Three sign
- B. 'E' Sign or 'Reverse Three sign' (Correct Answer)
- C. Prominent ascending aorta
- D. Rib notching
Explanation: ***'E' Sign or 'Reverse Three sign' (Reverse ε sign)*** - The **'E' sign** or **'reverse three sign'** is seen on **barium esophagram** (lateral view), NOT on a plain chest X-ray - On barium swallow, the esophagus shows indentation creating a reverse '3' or 'ε' shape due to impression from the dilated pre-stenotic aorta, the coarctation site, and the dilated post-stenotic aorta - **This is the correct answer** as the question asks specifically about plain chest radiograph findings - This sign requires contrast study and cannot be visualized on plain radiography *Three sign ('3' sign)* - The **'three sign'** is a **classic finding** in coarctation on plain chest X-ray (PA view) - Seen on the **left heart border** representing: (1) dilated left subclavian artery, (2) indentation at coarctation site, (3) post-stenotic dilation of descending aorta - Creates the shape of the numeral '3' along the aortic knuckle region - This is directly visible on plain radiograph *Prominent ascending aorta* - **Commonly seen** in coarctation due to increased afterload on the left ventricle - Results in **left ventricular hypertrophy** and dilation of the ascending aorta - Part of the cardiovascular remodeling in response to chronic pressure overload - Visible as widening of the superior mediastinum on plain chest X-ray *Rib notching* - **Classic finding** in long-standing coarctation of the aorta (usually after 5-6 years of age) - Due to **collateral circulation** through dilated intercostal arteries that erode the inferior rib margins - Typically affects **ribs 3-9** bilaterally - Represents chronic compensatory mechanism to bypass the obstruction
Question 5: With reference to Respiratory Distress Syndrome (RDS), which of the following statements is false?
- A. Leads to respiratory distress in premature infants
- B. Is less common in babies born to diabetic mothers (Correct Answer)
- C. Is treated by administering surfactant therapy
- D. Usually occurs in infants born before 34 weeks of gestation
Explanation: ***Is less common in babies born to diabetic mothers*** - Babies born to **diabetic mothers** are at an **increased risk** of Respiratory Distress Syndrome (RDS) due to delayed lung maturation caused by **hyperinsulinemia.** - Insulin inhibits the production of **surfactant**, a substance critical for reducing surface tension in the alveoli and preventing lung collapse. - This statement is **FALSE** - RDS is actually **MORE common** in infants of diabetic mothers. *Leads to respiratory distress in premature infants* - RDS is primarily a disease of **prematurity**, resulting from a deficiency of **surfactant** in the immature lungs. - This deficiency leads to widespread **atelectasis** (lung collapse), which causes breathing difficulties immediately or shortly after birth. - This statement is **TRUE**. *Is treated by administering surfactant therapy* - **Surfactant therapy** is a cornerstone of RDS treatment, often delivered via an **endotracheal tube**. - It works by replacing the deficient natural surfactant, thereby improving **lung compliance** and reducing the work of breathing. - This statement is **TRUE**. *Usually occurs in infants born before 34 weeks of gestation* - RDS predominantly affects infants born **before 34 weeks of gestation**, as their lungs are typically not mature enough to produce sufficient surfactant. - The risk **decreases significantly** with increasing gestational age, with full-term infants rarely developing the condition. - This statement is **TRUE**.
Question 6: Thumb sign in lateral X-ray of the neck is seen in?
- A. Epiglottitis (Correct Answer)
- B. Internal hemorrhage
- C. Saccular cyst
- D. Carcinoma of the epiglottis
Explanation: ***Epiglottitis*** - The **thumb sign** on a lateral neck X-ray is a classic finding in **acute epiglottitis**, caused by the severely swollen epiglottis. - This swelling can lead to severe **airway obstruction** due to its critical location. *Internal hemorrhage* - Internal hemorrhage in the neck might cause soft tissue swelling, but it typically does not produce the specific **"thumb sign" morphology** seen in epiglottitis. - Diagnosis relies more on **clinical signs of bleeding** and potentially imaging like CT scans to localize blood collections. *Saccular cyst* - A **saccular cyst** (or laryngocele) is a benign air-filled or fluid-filled sac - It would appear as a well-defined, often air-filled, or soft-tissue mass, not typically resembling the diffuse, inflamed "thumb" appearance of a swollen epiglottis. *Carcinoma of the epiglottis* - While a **carcinoma of the epiglottis** could cause epiglottic swelling or mass effect, it usually presents as a more irregular or focal mass rather than the uniform, bulbous swelling characteristic of the "thumb sign" in acute epiglottitis. - Carcinoma is also typically a chronic process, unlike the acute, rapidly progressing inflammation of epiglottitis.
Question 7: A 3-month-old child presents with indrawing of the chest and a respiratory rate of 52 breaths per minute. This condition can be classified as:
- A. SIRS
- B. Respiratory distress (Correct Answer)
- C. Tachypnoea
- D. ARDS
Explanation: ***Respiratory distress*** - **Indrawing of the chest** is a classic sign of increased work of breathing, indicating the child is struggling to oxygenate. - A respiratory rate of **52 breaths per minute in a 3-month-old** is significantly elevated and, combined with indrawing, points to respiratory distress. - According to **WHO IMCI guidelines**, chest indrawing in a child with fast breathing is classified as **pneumonia/respiratory distress** requiring immediate treatment. *SIRS* - **Systemic Inflammatory Response Syndrome (SIRS)** criteria are typically more comprehensive and include fever or hypothermia, tachycardia, tachypnea, and abnormal white blood cell count. - While tachypnea is present, the other defining features of SIRS are not fully met by the information provided, nor does indrawing directly classify as SIRS. *Tachypnoea* - **Tachypnoea** refers specifically to an elevated respiratory rate, which is present (52 breaths per minute). - However, the presence of **chest indrawing** indicates more than just rapid breathing; it signifies significant respiratory effort and compromise. - The classification must capture both the elevated rate and the increased work of breathing. *ARDS* - **Acute Respiratory Distress Syndrome (ARDS)** is a severe form of lung injury characterized by widespread inflammation, hypoxemia, and bilateral infiltrates on chest imaging. - While respiratory distress is a feature of ARDS, the given information is insufficient to diagnose ARDS, which requires specific criteria relating to oxygenation and radiological findings.
Question 8: A 10yr old boy with a known case of nephrotic syndrome since 4 years on treatment brought to the pediatric OPD with chief complaint of difficulty in breathing. There is no history of fever. On examination, respiratory system was normal except slightly reduced breath sounds on right infra-axillary region. Paediatrician thinks of pleural effusion. What is next best modality of investigation to detect pleural effusion?
- A. Lateral view Chest X-ray
- B. USG (Correct Answer)
- C. Erect Chest X-ray PA view
- D. Lateral decubitus view
Explanation: ***USG*** - **Ultrasound** is the **best first-line investigation** for detecting **pleural effusions** in children due to its **non-invasive nature**, lack of radiation exposure, and ability to detect even small effusions (as little as 5-10 mL). - It can effectively differentiate between pleural fluid and other pathologies (e.g., consolidation, masses) and guide aspiration if needed. - **Real-time bedside availability** makes it ideal for pediatric patients. *Lateral view Chest X-ray* - A lateral Chest X-ray only detects pleural effusion if the fluid volume is at least **75-100 mL**, which might miss smaller effusions. - While it can provide additional information about the lungs and mediastinum, it is not as sensitive as ultrasound for detecting small effusions. *Erect Chest X-ray PA view* - An erect Chest X-ray PA view requires a minimum of **200-300 mL of fluid** to blunt the **costophrenic angle**, potentially missing smaller effusions. - It involves **ionizing radiation**, a concern in pediatric patients, and is less sensitive than ultrasound for early detection. *Lateral decubitus view* - A lateral decubitus view is useful for confirming the presence of **free-flowing pleural fluid** and differentiating it from loculated effusions, typically after an initial effusion is suspected. - While sensitive for detecting small effusions (as little as **50 mL**), it is typically performed as a secondary investigation and involves radiation exposure, unlike ultrasound.
Question 9: One year old male child with cat's reflex and raised IOP. What is the most likely diagnosis?
- A. Toxocara canis
- B. Retinopathy of prematurity
- C. Retinoblastoma (Correct Answer)
- D. Toxoplasma gondii infection
Explanation: ***Retinoblastoma*** - A **cat's reflex (leukocoria)**, which is a white pupillary reflex, is the most common presenting sign of retinoblastoma in children. - **Raised intraocular pressure (IOP)** can occur in advanced retinoblastoma due to secondary glaucoma caused by tumor growth or neovascularization. *Toxocara canis* - Ocular **toxocariasis** can cause leukocoria and inflammation, but it's typically associated with **granuloma formation** and not usually primary elevated IOP. - This condition is caused by a **parasitic infection** from roundworms, often seen in children with exposure to contaminated soil or pets. *Retinopathy of prematurity* - Primarily affects **premature infants** exposed to high oxygen, leading to abnormal retinal vessel development. - While it can cause leukocoria in severe stages, it would be unusual for a **one-year-old** to present with this primary diagnosis especially with raised IOP. *Toxoplasma gondii infection* - Ocular **toxoplasmosis** typically presents with **chorioretinitis** and can cause inflammation, but **leukocoria** and **raised IOP** are not its primary or most characteristic features. - This is a parasitic infection, congenital or acquired, often presenting with **retinal scars**.
Question 10: Treatment of choice for antrochoanal polyp in a 10-year-old child-
- A. Caldwell luc's
- B. Exploratory rhinotomy
- C. Conservative treatment till 16 years
- D. Intranasal polypectomy (Correct Answer)
Explanation: ***Intranasal polypectomy*** - **Intranasal polypectomy**, particularly via **endoscopic sinus surgery**, is the preferred treatment for antrochoanal polyps in children due to its minimally invasive nature and ability to ensure complete removal of the polyp's antral component. - This approach allows for direct visualization and removal of the polyp, including its origin from the **maxillary sinus ostium**, which is crucial to prevent recurrence. *Caldwell luc's* - The Caldwell-Luc procedure is a more invasive technique that involves creating an antrostomy through the anterior wall of the maxillary sinus. - It is associated with higher morbidity, including potential for **facial swelling**, **nerve damage**, and **dental complications**, making it less favored, especially in children, for antrochoanal polyps. *Exploratory rhinotomy* - **Exploratory rhinotomy** is a highly invasive surgical approach typically reserved for extensive or malignant sinonasal tumors. - It is an overly aggressive and unnecessary procedure for a benign condition like an antrochoanal polyp. *Conservative treatment till 16 years* - Antrochoanal polyps cause symptoms like **nasal obstruction** and potential ostial blockage, leading to sinus infections. - Delaying treatment is not advisable as it can lead to chronic symptoms, impaired quality of life, and potential complications from untreated sinus disease.
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