Pediatric Surgery Practice Questions

Q: A 4-year-old girl is brought to the physician for a painless lump on her neck. She has no history of serious illness and her vital signs are within normal limits. On examination, there is a firm, 2-cm swelling at the midline just below the level of the hyoid bone. The mass moves cranially when she is asked to protrude her tongue. Which of the following is the most likely diagnosis?

Thyroglossal cyst. Thyroglossal cyst - A midline neck mass that moves cranially with tongue protrusion is the classic presentation of a thyroglossal duct cyst. - These cysts arise from the remnant of the thyroglossal duct, the embryonic tract along which the thyroid gland descends from the foramen cecum to its final position [1]. Cystic hygroma - This is a lymphatic malformation typically appearing as a soft, compressible, transilluminant mass, often in the posterior triangle of the neck. - It does not move with tongue protrusion and is usually not midline. Ranula - A ranula is a mucocele that forms in the floor of the mouth, usually due to obstruction of a sublingual salivary gland. - It presents as a swelling in the oral cavity, below the tongue, and not as an external neck mass. Dermoid cyst - A dermoid cyst in the neck is typically a painless, doughy, subcutaneous mass that is also usually midline but does not move with tongue protrusion. - These cysts are often found above the hyoid bone, unlike the typical position of a thyroglossal cyst.

Q: A 5-year-old boy is taken to his pediatrician for a laceration on his right knee. A mass on his neck is noticed; his mother states it has been there for several months and is slowly getting larger. The mass is slightly to the left of midline. What is the most likely diagnosis? Ultrasound of neck shows a midline hypoechoic mass anterior and superior to the thyroid gland.

Thyroglossal duct cyst. ***Thyroglossal duct cyst*** - A **thyroglossal duct cyst** is the most common congenital neck mass, typically presenting in children as a **midline** or slightly off-midline mass that moves with tongue protrusion. - The ultrasound finding of a **midline hypoechoic mass** anterior and superior to the thyroid gland is highly characteristic of this diagnosis. *Laryngocele* - A **laryngocele** is a rare, air-filled sac originating from the laryngeal ventricle, usually presenting as a **lateral neck mass** that may enlarge with Valsalva maneuvers. - It would typically be air-filled and located in the region of the larynx, not a solid or cystic mass superior to the thyroid. *Chondroma* - A **chondroma** is a benign tumor of cartilage, which can occur in various locations but is uncommon in the neck and would present as a **firm, non-mobile mass**, usually not in the midline anterior to the thyroid. - It would typically be a solid, cartilaginous lesion, and imaging would show calcifications consistent with cartilage, which is not indicated here. *Dermoid cyst* - A **dermoid cyst** can present as a midline neck mass, often found in children, but it typically does not migrate with tongue protrusion and would contain elements like **hair follicles and sebaceous glands**. - While dermoid cysts can be midline, their typical location and content often differentiate them from thyroglossal duct cysts.

Q: The metabolic derangement in congenital pyloric stenosis is -

Hypochloremic alkalosis. ***Hypochloremic alkalosis*** - **Pyloric stenosis** causes persistent vomiting of stomach contents, leading to the loss of **hydrochloric acid (HCl)** and subsequent **hypochloremia** and **metabolic alkalosis**. - The body's compensatory mechanisms are limited: with volume depletion, the kidneys prioritize sodium retention over acid-base balance, leading to **paradoxical aciduria** (excretion of H+ to retain Na+), which perpetuates the alkalosis. *Hyperchloremic alkalosis* - **Hyperchloremia** is an elevated chloride level, which is not characteristic of pyloric stenosis as profound vomiting leads to significant **chloride loss**. - While alkalosis is present, it is specifically **hypochloremic** due to the loss of gastric acid. *Hyperchloremic acidosis* - **Hyperchloremic acidosis** is often seen in conditions like **renal tubular acidosis** or **diarrhea**, where there is a loss of bicarbonate or retention of chloride, and is not associated with gastric outlet obstruction. - This condition involves a low pH (acidosis) and high chloride, which contradicts the clinical picture of pyloric stenosis characterized by high pH (alkalosis) and low chloride. *Hypochloremic acidosis* - This combination is rare and typically seen in conditions like very severe **diarrhea** with significant fluid and electrolyte loss alongside certain renal dysfunctions. - In pyloric stenosis, the primary acid-base disturbance is **alkalosis** due to the loss of gastric acid, not acidosis.

Q: All of the following are true about congenital hypertrophic pyloric stenosis except

Metabolic acidosis occurs. ***Metabolic acidosis occurs*** - Due to persistent **vomiting** from pyloric stenosis, there is a significant loss of **hydrochloric acid (HCl)** from the stomach. - This loss of gastric acid leads to **hypochloremic metabolic alkalosis** rather than acidosis. *More common in males* - **Pyloric stenosis** has a clear male predominance, with a male-to-female ratio of about 4:1. - This gender disparity is a well-established epidemiological feature of the condition. *RamStedt Pyloromyotomy is the treatment of choice* - The **Ramstedt pyloromyotomy** is the definitive surgical procedure for congenital hypertrophic pyloric stenosis. - This procedure involves incising the hypertrophied muscle of the pylorus while leaving the mucosa intact, thus relieving the obstruction. *Non Bilious vomiting is seen* - The vomiting in pyloric stenosis is typically **non-bilious** because the obstruction is proximal to the **ampulla of Vater**, where bile enters the duodenum. - Vomiting usually occurs forcefully (projectile) after feeding.

Q: Metabolic abnormalities associated with Congenital Pyloric Stenosis in the early phase include all EXCEPT:

Aciduria. ***Aciduria*** - In the early phase of congenital pyloric stenosis, **persistent vomiting** leads to loss of gastric acid (HCl), causing **hypochloremic metabolic alkalosis**. - Initially, the kidneys excrete **alkaline urine** (with bicarbonate) to compensate for the alkalosis. - **Paradoxical aciduria** develops later as a compensatory mechanism when severe volume depletion and hypokalemia persist, NOT in the early phase. - Therefore, aciduria is the correct answer as it is **NOT an early metabolic abnormality**. *Hypokalemia* - Loss of gastric fluid containing potassium directly contributes to **potassium depletion**. - Volume depletion triggers **aldosterone secretion**, causing increased renal potassium excretion and sodium retention. - This is a **characteristic early finding** in pyloric stenosis. *Hypochloremia* - Persistent vomiting results in significant loss of **hydrochloric acid (HCl)** from the stomach. - This directly depletes chloride ions, causing **hypochloremia**. - This is a **hallmark early finding**, part of the classic hypochloremic metabolic alkalosis. *None of the options* - This is incorrect because **aciduria is indeed NOT an early finding** (it is a late/paradoxical finding). - Since the question asks for the exception using "EXCEPT," and aciduria correctly represents what is NOT seen early, this option is wrong.

Q: Earliest tumour to appear after birth is?

Cystic hygroma. ***Cystic hygroma*** - A cystic hygroma is a **congenital lymphatic malformation** that is most commonly **present at birth or becomes evident in the immediate neonatal period**, making it the earliest to be clinically apparent among the given options. - It arises from sequestration of lymphatic tissue that fails to connect with the venous system, often presenting as a **soft, compressible, transilluminant mass** typically in the posterior triangle of the neck or axilla. - **60-80% are detected at birth**, and 90% by 2 years of age, making it the earliest "tumor" (though technically a malformation) to be recognized in newborns. *Sternomastoid tumour* - This is a fibrous pseudotumor (not a true neoplasm) within the **sternocleidomastoid muscle**, typically noticed at **2-4 weeks of age** following **birth trauma** or abnormal in-utero positioning. - It leads to **congenital muscular torticollis** and appears as a firm, non-tender, mobile mass in the muscle belly. - Though early, it appears **later than cystic hygroma** in the neonatal period. *Branchial cyst* - Branchial cysts are **congenital cervical anomalies** arising from remnants of the **branchial apparatus** that typically present **later in childhood or early adulthood** as they enlarge. - They are rarely symptomatic or clinically apparent at birth, often becoming evident only when infected or significantly enlarged. *Lymphoma* - Lymphomas are malignancies of lymphoid tissue that are **extremely rare in neonates** and infants. - Congenital lymphomas are exceptionally uncommon and not considered among the earliest tumors to appear after birth.

Q: What is the definitive treatment for Tetralogy of Fallot (TOF)?

Complete repair. ***Complete repair*** - **Complete repair** is the definitive treatment for TOF, addressing all four anatomical defects. This typically involves closing the **ventricular septal defect (VSD)** and relieving the **right ventricular outflow tract (RVOT) obstruction**. - This procedure usually occurs between 3 to 6 months of age, or earlier if the child experiences severe cyanosis or hypercyanotic spells. *Modified Blalock-Taussig shunt* - The **Modified Blalock-Taussig shunt** is a palliative procedure, not a definitive one. It creates a connection between a systemic artery (often the subclavian) and the pulmonary artery. - This shunt increases **pulmonary blood flow** in infants with severe cyanosis, bridging them to a time when definitive repair can be safely performed. *Fontan procedure* - The **Fontan procedure** is a surgical intervention used for complex congenital heart defects with a **single functional ventricle**, such as hypoplastic left heart syndrome. - It reroutes systemic venous return directly to the pulmonary arteries, bypassing the non-functional ventricle, which is not the primary issue in TOF. *Glenn shunt* - The **Glenn shunt** (or superior cavopulmonary connection) is another palliative procedure, typically performed as the second stage in single-ventricle repair strategies. - It connects the **superior vena cava** to the **pulmonary artery**, diverting upper body venous blood directly to the lungs, and allowing the single ventricle to pump only systemic blood. This is not applicable as a definitive solution for TOF.

Q: A one-month-old female child has a swelling over the back in the sacral region. There is no cough impulse in the swelling. X-ray examination shows erosion of the coccyx. The most likely clinical diagnosis would be -

Sacro-coccygeal teratoma. ***Sacro-coccygeal teratoma*** - The presence of a swelling in the **sacral region** with **erosion of the coccyx** in a one-month-old infant is highly suggestive of a sacro-coccygeal teratoma. - The absence of a **cough impulse** helps rule out conditions with a neural connection that would transmit increased intracranial pressure to the swelling. *Lipoma* - A lipoma is a benign tumor of **fat cells** and typically does not cause **bone erosion**. - While it can be a soft swelling, its clinical presentation would not include **coccygeal erosion**. *Meningocele* - A meningocele is a protrusion of the **meninges** through a defect in the spine, containing **cerebrospinal fluid**. - It would typically exhibit a **cough impulse** due to its connection with the subarachnoid space and increased intracranial pressure. *Neurofibroma* - A neurofibroma is a tumor of the **nerve sheath** and is less common in the sacral region in neonates causing such significant bone destruction. - While it can present as a soft tissue mass, **coccygeal erosion** is not a typical feature unless it is a very aggressive, infiltrative tumor.

Question 1

A 4-year-old girl is brought to the physician for a painless lump on her neck. She has no history of serious illness and her vital signs are within normal limits. On examination, there is a firm, 2-cm swelling at the midline just below the level of the hyoid bone. The mass moves cranially when she is asked to protrude her tongue. Which of the following is the most likely diagnosis?

Accepted Answer

Thyroglossal cyst

Answer

Cystic hygroma

Answer

Ranula

Answer

Dermoid cyst

Question 2

A 6-month-old child presents with an umbilical hernia measuring 3 cm in diameter. What is the management protocol?

Accepted Answer

Observation until 2 years of age, then surgery if unresolved

Answer

Immediate surgical repair

Answer

Elective surgery at 5 years of age

Answer

Hernioplasty for repair

Question 3

A 5-year-old boy is taken to his pediatrician for a laceration on his right knee. A mass on his neck is noticed; his mother states it has been there for several months and is slowly getting larger. The mass is slightly to the left of midline. What is the most likely diagnosis?

Ultrasound of neck shows a midline hypoechoic mass anterior and superior to the thyroid gland.

Accepted Answer

Thyroglossal duct cyst

Answer

Laryngocele

Answer

Chondroma

Answer

Dermoid cyst

Question 4

The metabolic derangement in congenital pyloric stenosis is -

Accepted Answer

Hypochloremic alkalosis

Answer

Hyperchloremic alkalosis

Answer

Hyperchloremic acidosis

Answer

Hypochloremic acidosis

Question 5

All of the following are true about congenital hypertrophic pyloric stenosis except

Accepted Answer

Metabolic acidosis occurs

Answer

More common in males

Answer

RamStedt Pyloromyotomy is the treatment of choice

Answer

Non Bilious vomiting is seen

Question 6

Metabolic abnormalities associated with Congenital Pyloric Stenosis in the early phase include all EXCEPT:

Accepted Answer

Aciduria

Answer

Hypokalemia

Answer

Hypochloremia

Answer

None of the options

Question 7

A child presented with intermittent episodes of left sided flank pain. Ultrasonography reveals large hydronephrosis with dilated renal pelvis and cortical thinning with a normal ureter. Kidney differential function was observed to be 19%. Which of the following is the best management?

Accepted Answer

Pyeloplasty

Answer

Endopylostomy

Answer

Nephrectomy

Answer

External drainage

Question 8

Earliest tumour to appear after birth is?

Accepted Answer

Cystic hygroma

Answer

Sternomastoid tumour

Answer

Branchial cyst

Answer

Lymphoma

Question 9

What is the definitive treatment for Tetralogy of Fallot (TOF)?

Accepted Answer

Complete repair

Answer

Modified Blalock-Taussig shunt

Answer

Fontan procedure

Answer

Glenn shunt

Question 10

A one-month-old female child has a swelling over the back in the sacral region. There is no cough impulse in the swelling. X-ray examination shows erosion of the coccyx. The most likely clinical diagnosis would be -

Accepted Answer

Sacro-coccygeal teratoma

Answer

Lipoma

Answer

Meningocele

Answer

Neurofibroma

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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