Pediatric Surgery Practice Questions

Q: A neonate presents with a doughy soft lump in the neck causing distortion of face and audible grunt, as shown in the image. Diagnosis is:

Cystic hygroma. ***Cystic hygroma*** - A **cystic hygroma** is a **congenital lymphatic malformation** typically presenting as a soft, doughy mass in the neck, which can be quite large and cause facial distortion and respiratory distress (indicated by an audible grunt). - Its presence at birth, large size, soft consistency, and impact on adjacent structures are classic features of a cystic hygroma. *Brachial cyst* - A **branchial cleft cyst** usually appears as a **well-defined, smooth lump** on one side of the neck, typically along the anterior border of the sternocleidomastoid muscle. - While congenital, these cysts are usually **smaller** and less likely to cause widespread facial distortion or immediate respiratory compromise in a neonate compared to a large cystic hygroma. *Sternocleidomastoid tumor* - A **sternocleidomastoid tumor** (fibromatosis colli) is a firm, non-tender mass within the sternocleidomastoid muscle, usually appearing a few weeks after birth. - It typically causes **torticollis** (head tilt) and is **firm to rubbery**, not doughy, and rarely causes facial distortion or respiratory grunting. *Birth injury* - **Birth injuries** to the neck might include hematomas or nerve damage, but they would typically present with **bruising**, swelling, or neurological deficits, rather than a soft, persistent, doughy lump causing facial distortion and grunting. - A large hematoma might be firm initially and would typically resolve over time, not present as a soft, fluid-filled mass.

Q: A neonate presents with a soft, compressible, translucent cystic mass in the neck region, present since birth. What is the most likely diagnosis?

Lymphangioma. ***Lymphangioma*** - The clinical presentation of a **soft, compressible, translucent cystic mass** in the neck of a neonate is characteristic of **cervical lymphangioma** (also known as cystic hygroma) - These are **congenital malformations of the lymphatic system** that typically present at birth or within the first two years of life - The mass is usually **transilluminable** due to its fluid-filled nature, which is a key diagnostic feature - Most commonly located in the **posterior triangle of the neck** *Branchial cyst* - **Branchial cleft cysts** present as lateral neck masses, typically anterior to the sternocleidomastoid muscle - They usually become **clinically apparent later in childhood** or adolescence, often after an upper respiratory infection - The mass is more **circumscribed and firm**, not typically transilluminant like lymphangiomas - Less common in neonates compared to lymphangiomas *Hemangioma* - **Infantile hemangiomas** can present as neck masses but typically have a **vascular appearance** with overlying skin changes (red or purple discoloration) - They are **not transilluminant** and feel more solid or rubbery rather than cystic - Hemangiomas often show **rapid growth phase** during early infancy (proliferative phase) followed by involution - They do not typically present as translucent cystic masses *Mumps* - **Mumps** causes painful swelling of the **parotid glands**, located in front of and below the ears - It is a **viral infection** (paramyxovirus), not a congenital condition - Presentation in neonates is **extremely rare** due to maternal antibody protection - The swelling is **bilateral**, tender, and associated with systemic symptoms (fever, malaise), not a solitary translucent mass

Q: A 3-year-old child presents with swelling in scrotum since birth. Transillumination test is positive. All are true except:

Bag of worms. ***Bag of worms*** - A "bag of worms" sensation on palpation of the scrotum is characteristic of a **varicocele**, which is an enlargement of the pampiniform plexus of testicular veins. - The presented case describes a **hydrocele**, characterized by scrotal swelling since birth and positive transillumination, which is a collection of fluid, not dilated veins. *Herniotomy* - A persistent **patent processus vaginalis** is the underlying cause of a communicating infantile hydrocele. - **Herniotomy** is the surgical procedure performed to ligate and excise the patent processus vaginalis, thereby treating the hydrocele and preventing future herniation. *USG for patent processus vaginalis* - **Ultrasound (USG)** is a common diagnostic tool used to assess scrotal swelling and can identify a patent processus vaginalis, which is the communication between the peritoneal cavity and the tunica vaginalis, responsible for a communicating hydrocele. - This imaging confirms the presence of fluid within the tunica vaginalis and, potentially, the communicating channel, helping to differentiate from other causes of scrotal swelling. *Does not reduce on supine position* - A typical **communicating hydrocele** may fluctuate in size but generally **does not reduce** completely on a change in position, unlike an inguinal hernia which often reduces when the child is supine. - This is because the fluid within the tunica vaginalis cannot easily drain back into the peritoneal cavity, especially if the communication is small or intermittently obstructed.

Q: Which of the following is incorrect about the image shown?

Always presents with stridor. ***Always presents with stridor*** - This statement is **incorrect** because stridor is **not a universal presentation** of cystic hygroma. - Stridor only develops when the lesion is large enough or positioned to compress the airway (typically **cervical location near trachea**). - Many cystic hygromas, particularly **smaller ones** or those located away from respiratory structures, do **not present with stridor** at all. - Other presentations include **painless neck mass**, **dysphagia**, or **incidental prenatal finding**. *Occurs due to failure of lymphatics to connect to venous system* - This accurately describes the **primary embryological defect** in cystic hygroma formation. - Primitive lymphatic sacs fail to connect to the venous system, leading to **accumulation of lymphatic fluid** and formation of the characteristic multiloculated cystic mass. *Associated with Turner syndrome* - Cystic hygromas are strongly associated with **Turner syndrome (45,X)**, particularly **nuchal cystic hygromas** detected prenatally. - Other chromosomal abnormalities such as **trisomy 13, 18, and 21** also show increased association with cystic hygromas. *CT scan for mediastinal extension* - **CT or MRI imaging** is essential for assessing the full extent of cystic hygromas and identifying **mediastinal, laryngeal, or airway involvement**. - This imaging is crucial for **surgical planning** and anticipating potential complications such as respiratory compromise.

Q: This new-born baby presented with respiratory distress soon after birth. Which of the following is not a correct association about this condition?

Always associated with absence of gas shadows in abdomen. ***Always associated with absence of gas shadows in abdomen*** ✗ **This is the INCORRECT statement** - The image depicts a newborn with **esophageal atresia** and a **tracheoesophageal fistula (TEF)**, characterized by thick, frothy secretions and respiratory distress. - While esophageal atresia without TEF can cause an absence of gas shadows, **over 85% of cases involve a distal TEF**, allowing air from the trachea to enter the stomach and intestines, resulting in **present gas shadows** on X-ray. - Therefore, this condition is **NOT always** associated with absence of gas shadows - in fact, gas is usually present. *Maternal polyhydramnios* ✓ **Correct association** - **Polyhydramnios** is a common association with esophageal atresia, as the fetus is unable to swallow amniotic fluid. - This leads to an excessive accumulation of amniotic fluid in the uterus, often detected antenatally. *Can be associated with anorectal malformations* ✓ **Correct association** - Esophageal atresia is frequently part of the **VACTERL association** (Vertebral defects, Anorectal malformations, Cardiac defects, Tracheoesophageal fistula, Esophageal atresia, Renal anomalies, and Limb defects). - Therefore, **anorectal malformations** can indeed be found in conjunction with this condition. *Surgery is definitive treatment* ✓ **Correct association** - **Surgical correction** of the esophageal atresia and repair of any associated tracheoesophageal fistula is the definitive treatment. - This procedure aims to restore continuity of the esophagus and prevent aspiration, allowing for normal feeding and respiratory function.

Q: Identify the disease shown in the image.

Pectus carinatum. ***Pectus carinatum*** - The image clearly shows a prominent, protruding sternum and chest wall, which is the characteristic clinical presentation of **pectus carinatum**, also known as "pigeon chest." - This condition results from an **abnormal growth of cartilage** connecting the ribs to the breastbone, pushing the sternum outward. *Gigantism* - Gigantism is characterized by **excessive growth** and height due to overproduction of growth hormone before the epiphyseal plates close. - It does not primarily manifest as a specific chest wall deformity but rather as overall accelerated growth. *Acromegaly* - Acromegaly results from **excessive growth hormone** production after the epiphyseal plates have closed, leading to enlarged hands, feet, and facial features. - While it causes bone overgrowth, it typically involves the extremities and skull, not specifically the sternum in the manner shown. *Goiter* - Goiter refers to an **enlargement of the thyroid gland**, located in the neck. - It presents as a swelling in the anterior neck, not as a chest wall deformity.

Q: All of the following statements regarding this image are true except: (Recent NEET Pattern 2016-17)

Rate of reoccurrence is 50 % after nonoperative reduction. ***Rate of reoccurrence is 50% after nonoperative reduction*** - The recurrence rate after successful nonoperative reduction of intussusception is typically around **5-10%**, not as high as 50%. - A 50% recurrence rate would suggest a highly unstable reduction or a strong underlying predisposing factor that is not being addressed. *Ileo-colic variety is common in children* - **Ileo-colic intussusception** is indeed the most common type of intussusception, especially in children, accounting for approximately 90% of cases. - This anatomical location is where the **ileum telescopes into the cecum and colon**, which is often depicted in images like the one provided. *70% of the cases can be reduced nonoperatively* - **Nonoperative reduction** using air or hydrostatic enema is successful in a significant majority of intussusception cases, with success rates often reported between **70-90%**. - This makes nonoperative reduction the first-line treatment in stable patients without signs of peritonitis or perforation. *Baby presents with red currant jelly stools* - **Red currant jelly stools**, which are a mixture of **blood and mucus**, are a classic symptom of intussusception, particularly in infants. - This symptom results from **ischemia and sloughing of the intestinal mucosa** due to compromised blood supply.

Q: Which of the following statements are correct regarding Inguinal hernias in children? I. It is more common in premature boys. II. It should be repaired promptly. III. It is always indirect. IV. It may frequently be transilluminant. Select the answer using the code given below :

I, II and III. ***I, II and III*** - **Statement I is correct**: Inguinal hernias are significantly **more common in premature boys**, with an incidence of up to **30% in preterm infants** compared to 3-5% in term infants. Male predominance is marked (6-10:1 ratio). - **Statement II is correct**: Pediatric inguinal hernias should be **repaired promptly** (elective basis) due to the high risk of **incarceration and strangulation**, especially in infants under 1 year where the risk can be as high as 31%. - **Statement III is correct**: All inguinal hernias in children are **indirect hernias**, occurring through a **patent processus vaginalis**. Direct hernias are extremely rare in the pediatric population and represent adult pathology. - **Statement IV is incorrect**: Inguinal hernias are typically **NOT transilluminant** because they contain solid abdominal contents like bowel or omentum. **Transillumination** is a characteristic feature of **hydroceles** (fluid-filled), not hernias. *II and III* - While statements II and III are correct, this option is **incomplete** as it omits Statement I, which is also factually correct regarding the increased incidence in premature boys. *I, III and IV* - Statements I and III are correct, but **Statement IV is false**. Inguinal hernias do **not transilluminate** because they contain bowel or omentum, not fluid. Transillumination distinguishes hydroceles from hernias. *I, II and IV* - Statements I and II are correct, but **Statement IV is false** (hernias are not transilluminant), and Statement III is omitted despite being a fundamental characteristic of pediatric inguinal hernias (always indirect).

Q: The most common site of urethral opening in cases of hypospadias is :

Just proximal to the glans. ***Just proximal to the glans*** - The most frequent location for the urethral opening in **hypospadias** is the **subcoronal** or glanular region, which is just proximal to the glans. - This accounts for approximately 50-70% of all hypospadias cases, making it the **mildest and most common form**. *On the penile shaft* - While hypospadias can manifest with an opening on the **penile shaft** (midshaft or proximal shaft), these are less common than glanular or subcoronal types. - Penile shaft hypospadias usually indicates a more severe form compared to distal types and often presents with more significant **chordee**. *On the perineum* - An opening on the **perineum** represents the most severe form of hypospadias, often classified as **perineal hypospadias**. - This severe anomaly is associated with other urogenital defects and often presents with a **bifid scrotum** and ambiguous genitalia, which are rare compared to distal forms. *At the junction of penile shaft and scrotum* - This location, called **penoscrotal hypospadias**, is another severe form but is still less common than glanular or subcoronal types. - **Penoscrotal hypospadias** is characterized by a high degree of **chordee** and usually requires more complex surgical correction.

Question 1

A neonate presents with a doughy soft lump in the neck causing distortion of face and audible grunt, as shown in the image. Diagnosis is:

Accepted Answer

Cystic hygroma

Answer

Brachial cyst

Answer

Sternocleidomastoid tumor

Answer

Birth injury

Question 2

A neonate presents with a soft, compressible, translucent cystic mass in the neck region, present since birth. What is the most likely diagnosis?

Accepted Answer

Lymphangioma

Answer

Branchial cyst

Answer

Hemangioma

Answer

Mumps

Question 3

A 3-year-old child presents with swelling in scrotum since birth. Transillumination test is positive. All are true except:

Accepted Answer

Bag of worms

Answer

Herniotomy

Answer

USG for patent processus vaginalis

Answer

Does not reduce on supine position

Question 4

Which of the following is incorrect about the image shown?

Accepted Answer

Always presents with stridor

Answer

Associated with Turner syndrome

Answer

CT scan for mediastinal extension

Answer

Occurs due to failure of lymphatics to connect to venous system

Question 5

This new-born baby presented with respiratory distress soon after birth. Which of the following is not a correct association about this condition?

Accepted Answer

Always associated with absence of gas shadows in abdomen

Answer

Maternal polyhydramnios

Answer

Can be associated with anorectal malformations

Answer

Surgery is definitive treatment

Question 6

Identify the disease shown in the image.

Accepted Answer

Pectus carinatum

Answer

Gigantism

Answer

Acromegaly

Answer

Goiter

Question 7

All of the following statements regarding this image are true except: (Recent NEET Pattern 2016-17)

Accepted Answer

Rate of reoccurrence is 50 % after nonoperative reduction

Answer

Ileo-colic variety is common in children

Answer

70 % of the cases can be reduced nonoperatively

Answer

Baby presents with red currant jelly stools

Question 8

Which of the following statements are correct regarding Inguinal hernias in children?
I. It is more common in premature boys.
II. It should be repaired promptly.
III. It is always indirect.
IV. It may frequently be transilluminant.

Select the answer using the code given below :

Accepted Answer

I, II and III

Answer

II and III

Answer

I, III and IV

Answer

I, II and IV

Question 9

The most common site of urethral opening in cases of hypospadias is :

Accepted Answer

Just proximal to the glans

Answer

On the penile shaft

Answer

On the perineum

Answer

At the junction of penile shaft and scrotum

Question 10

A 5-year-old male child comes with a left sided scrotal swelling which has no cough impulse and does not reduce on compression or lying down but the parents give a definite history that swelling is absent in the morning and comes by in the evening. The best treatment is :

Accepted Answer

Herniotomy

Answer

Eversion of sac

Answer

To leave it alone (masterly inactivity)

Answer

Hernioplasty

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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