Vocal Cord Paralysis Indian Medical PG Practice Questions and MCQs
Practice Indian Medical PG questions for Vocal Cord Paralysis. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Vocal Cord Paralysis Indian Medical PG Question 1: A patient presents with hoarseness and laryngoscopy reveals a warty, cauliflower-like growth on the vocal cord. Identify the most likely lesion.
- A. Laryngeal papilloma (Correct Answer)
- B. Laryngeal malignancy
- C. Tracheomalacia
- D. Reinke’s edema
Vocal Cord Paralysis Explanation: ***Laryngeal papilloma***
- **Hoarseness** and a **warty, cauliflower-like growth** on the vocal cord are classic descriptions of a laryngeal papilloma, often caused by **HPV infection**.
- These lesions can be solitary or multiple, and while benign, they can recur and cause voice changes and respiratory obstruction.
*Laryngeal malignancy*
- While hoarseness is a common symptom of laryngeal malignancy, the description of a **"warty, cauliflower-like growth"** is more characteristic of a papilloma than most typical carcinomas, which might appear more ulcerative or infiltrative.
- Malignancies are more commonly associated with risk factors like **smoking and alcohol use**, and often present with other symptoms like dysphagia or weight loss.
*Tracheomalacia*
- **Tracheomalacia** refers to softening of the tracheal cartilage, leading to airway collapse, typically causing stridor or respiratory distress.
- It does not present as a **discrete growth** on the vocal cords but rather as a diffuse structural weakness of the trachea.
*Reinke’s edema*
- **Reinke's edema** (polypoid corditis) is characterized by a **gelatinous or fluid-filled swelling** of the vocal cords, usually associated with chronic irritation like smoking.
- It presents as a swollen, boggy appearance of the vocal cords, not a warty or cauliflower-like growth.
Vocal Cord Paralysis Indian Medical PG Question 2: A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
- A. FB in larynx
- B. Angioneurotic edema (Correct Answer)
- C. Parapharyngeal abscess
- D. FB bronchus
Vocal Cord Paralysis Explanation: Andioneurotic edema
- The combination of **tongue swelling**, **neck swelling**, **stridor**, and **hoarseness of voice** following peanut ingestion is highly suggestive of **angioneurotic edema**, a severe allergic reaction that can lead to airway obstruction [1].
- This is a life-threatening condition requiring immediate medical intervention, often associated with generalized **anaphylaxis** when triggered by allergens [2].
*FB in larynx*
- While a **foreign body (FB) in the larynx** can cause stridor and hoarseness, the widespread swelling of the tongue and neck points away from a localized laryngeal obstruction [3].
- A laryngeal FB would typically be associated with a more sudden onset of choking and coughing, not diffuse edema [3].
*Parapharyngeal abscess*
- A **parapharyngeal abscess** would typically present with **fever**, **severe throat pain**, and **trismus** (difficulty opening the mouth), which are not mentioned in this scenario.
- The acute, rapid onset of symptoms after peanut consumption is inconsistent with the slower progression of an abscess.
*FB bronchus*
- A **foreign body in the bronchus** would primarily cause **coughing**, **wheezing**, and possibly **respiratory distress**, often unilateral, rather than severe global swelling of the tongue and neck.
- Inspiratory stridor and hoarseness are more indicative of upper airway involvement than bronchial obstruction.
Vocal Cord Paralysis Indian Medical PG Question 3: Following total thyroidectomy, the patient develops respiratory stridor. The cause is:
- A. Unilateral recurrent laryngeal nerve paralysis
- B. Unilateral phrenic nerve paralysis
- C. Bilateral phrenic nerve paralysis
- D. Bilateral recurrent laryngeal nerve paralysis (Correct Answer)
Vocal Cord Paralysis Explanation: ***Bilateral recurrent laryngeal nerve paralysis***
- **Bilateral recurrent laryngeal nerve paralysis** is a serious complication of total thyroidectomy, leading to **adductor paralysis** of both vocal cords.
- This results in a narrowed airway, causing inspiratory **stridor**, **dyspnea**, and potentially acute respiratory obstruction requiring reintubation or tracheostomy.
*Unilateral recurrent laryngeal nerve paralysis*
- **Unilateral recurrent laryngeal nerve paralysis** typically causes **hoarseness** due to the inability of one vocal cord to adduct properly.
- It does not usually cause **stridor** or significant respiratory distress because the other vocal cord can still compensate for airway patency.
*Unilateral phrenic nerve paralysis*
- **Unilateral phrenic nerve paralysis** affects one side of the **diaphragm**, causing **dyspnea** and reduced lung capacity, particularly during exertion.
- It does not directly cause **stridor**, which is a sound produced by turbulent airflow through a narrowed upper airway.
*Bilateral phrenic nerve paralysis*
- **Bilateral phrenic nerve paralysis** causes severe **respiratory failure** due to complete paralysis of the **diaphragm**, requiring mechanical ventilation.
- While life-threatening, it does not directly manifest as **stridor**, as the primary issue is the inability to move air in and out through the lower respiratory system, not an obstruction in the upper airway.
Vocal Cord Paralysis Indian Medical PG Question 4: Which of the following conditions is least likely to cause bilateral recurrent laryngeal nerve palsy?
- A. Thyroid carcinoma
- B. Lymphadenopathy
- C. Thyroid surgery
- D. Aortic aneurysm (Correct Answer)
Vocal Cord Paralysis Explanation: ***Aortic aneurysm***
- An aortic aneurysm, especially of the ascending aorta, is **less likely to cause bilateral recurrent laryngeal nerve palsy** because the left recurrent laryngeal nerve typically hooks under the aortic arch, while the right nerve hooks under the subclavian artery.
- For **bilateral involvement**, two separate and simultaneous lesions affecting both nerves would be required at different anatomical locations with this etiology, making it a rare cause.
*Thyroid carcinoma*
- An aggressive **thyroid carcinoma** can directly invade or compress the recurrent laryngeal nerves (RLNs) due to their proximity to the thyroid gland.
- If the carcinoma is extensive or multifocal, it can lead to **bilateral involvement** by affecting both nerves.
*Lymphadenopathy*
- Significant **cervical or mediastinal lymphadenopathy** (e.g., due to metastatic disease or lymphoma) can compress or encase both recurrent laryngeal nerves.
- This proximity allows for potential **bilateral compression or damage** to the nerves as they ascend in the tracheoesophageal grooves.
*Thyroid surgery*
- **Thyroidectomy** is a common cause of recurrent laryngeal nerve injury due to the nerves' close anatomical relationship with the thyroid gland.
- **Bilateral recurrent laryngeal nerve palsy** can occur if both nerves are damaged during dissection, often due to surgical misidentification, thermal injury, or traction.
Vocal Cord Paralysis Indian Medical PG Question 5: A high tracheostomy may be indicated in:
- A. Advanced carcinoma of the larynx
- B. Severe bilateral vocal cord paralysis (Correct Answer)
- C. Chronic scleroma involving the larynx
- D. Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)
Vocal Cord Paralysis Explanation: ***Severe bilateral vocal cord paralysis***
- **High tracheostomy** may be indicated in severe bilateral vocal cord paralysis, particularly when both cords are paralyzed in the **median (adducted) position**, causing critical airway obstruction.
- A high tracheostomy is performed at the level of the **2nd or 3rd tracheal ring**, closer to the site of obstruction at the glottic level, providing immediate airway access.
- This can serve as temporary relief while definitive treatments like **arytenoidectomy, cordectomy, or vocal cord lateralization** are planned.
- In emergency situations, high tracheostomy or cricothyroidotomy may be life-saving.
*Advanced carcinoma of the larynx*
- High tracheostomy is **contraindicated** in laryngeal carcinoma as it may:
- Transect through tumor tissue
- Cause tumor seeding in the tracheal stoma
- Compromise subsequent **total laryngectomy** procedures
- **Low tracheostomy** (below the tumor, at 4th-5th tracheal ring) is the standard approach to secure the airway while avoiding tumor interference.
*Chronic scleroma involving the larynx*
- Scleroma typically causes **subglottic stenosis** and involves extensive tracheal disease.
- **Low tracheostomy** is preferred to bypass the diseased area completely.
- A high tracheostomy would be too close to the pathological process, risking inadequate airway and complications.
*Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)*
- Tracheostomy is generally **avoided** in RRP due to the significant risk of **seeding papillomas** into the tracheal stoma and lower airways.
- Management focuses on **repeated endoscopic laser ablation** or surgical excision to preserve laryngeal function.
- If tracheostomy is absolutely necessary, meticulous technique and close follow-up are required.
Vocal Cord Paralysis Indian Medical PG Question 6: During thyroidectomy, damage to which nerve leads to loss of high-pitched voice?
- A. External branch of the superior laryngeal nerve (Correct Answer)
- B. Hypoglossal nerve
- C. Vagus nerve
- D. Recurrent laryngeal nerve
Vocal Cord Paralysis Explanation: ***External branch of the superior laryngeal nerve***
- The **external branch of the superior laryngeal nerve** innervates the **cricothyroid muscle**, which is responsible for tensing the vocal cords.
- Damage to this nerve paralyzes the cricothyroid muscle, leading to an inability to tense the vocal cords, resulting in a **monotonous voice** and **loss of high-pitched tones**.
*Hypoglossal nerve*
- The **hypoglossal nerve (CN XII)** controls the muscles of the **tongue**, affecting articulation and swallowing, but not vocal pitch directly.
- Damage primarily causes **tongue deviation** and **difficulty with speech (dysarthria)** and swallowing.
*Vagus nerve*
- The **vagus nerve (CN X)** gives rise to both the **superior laryngeal nerve** and the **recurrent laryngeal nerve**.
- While damage to the vagus nerve trunk would affect vocalization, the question specifically asks about loss of high-pitched voice, which points to a more localized injury to one of its branches.
*Recurrent laryngeal nerve*
- The **recurrent laryngeal nerve** innervates most of the intrinsic laryngeal muscles, including the **thyroarytenoid** and **posterior cricoarytenoid muscles**, primarily affecting vocal cord adduction and abduction.
- Damage typically causes **hoarseness** due to vocal cord paralysis, and in severe cases, difficulty breathing, but it does not specifically lead to the *loss of high-pitched voice* as directly as superior laryngeal nerve damage.
Vocal Cord Paralysis Indian Medical PG Question 7: Most common nerve injured in ligation of inferior thyroid artery
- A. Sympathetic trunk
- B. Phrenic nerve
- C. Recurrent laryngeal nerve (Correct Answer)
- D. External branch of superior laryngeal nerve
Vocal Cord Paralysis Explanation: **Recurrent laryngeal nerve**
- The **recurrent laryngeal nerve (RLN)** runs in close proximity to the inferior thyroid artery, especially on the right side, making it highly vulnerable during ligation or thyroid surgery.
- Injury to the RLN can cause **hoarseness** due to paralysis of the vocal cords, as it innervates most intrinsic laryngeal muscles.
*Sympathetic trunk*
- The **sympathetic trunk** lies more medially and posteriorly in the neck, generally not in the immediate surgical field for inferior thyroid artery ligation.
- Injury to the sympathetic trunk typically leads to **Horner's syndrome** (ptosis, miosis, anhidrosis).
*Phrenic nerve*
- The **phrenic nerve** courses over the anterior scalene muscle, lateral to the thyroid gland and major vessels, making it relatively safe during standard thyroid surgery.
- Damage to the phrenic nerve would result in **diaphragmatic paralysis** and respiratory compromise.
*External branch of superior laryngeal nerve*
- The **external branch of the superior laryngeal nerve (EBSLN)** is located more superiorly, running with the superior thyroid artery to the cricothyroid muscle.
- Injury to the EBSLN would affect the **pitch of the voice** but is less commonly injured during inferior thyroid artery ligation compared to the RLN.
Vocal Cord Paralysis Indian Medical PG Question 8: A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?
- A. Direct laryngoscopy with biopsy (Correct Answer)
- B. MRI of neck
- C. CT scan of neck
- D. Radiotherapy
Vocal Cord Paralysis Explanation: ***Direct laryngoscopy with biopsy***
- A definitive diagnosis of a vocal cord mass requires **histological examination** to rule out malignancy, especially given the patient's risk factors (age, smoking) and symptoms (hoarseness, dysphagia, weight loss).
- **Direct laryngoscopy** allows for a thorough, magnified view of the mass and precise biopsy collection, which is superior to flexible laryngoscopy alone for definitive diagnosis and staging.
*MRI of neck*
- While MRI can provide excellent soft tissue detail for **staging** a known malignancy, it cannot provide a **histological diagnosis**.
- It would typically be performed after a biopsy confirms malignancy to assess the extent of the tumor and potential spread.
*CT scan of neck*
- A CT scan is useful for evaluating **bony involvement**, lymph node status, and tumor extension for **staging purposes**, but it is not a diagnostic tool for identifying the specific type of tissue or cell pathology.
- Like MRI, a CT scan would generally follow a biopsy confirming malignancy.
*Radiotherapy*
- **Radiotherapy** is a treatment modality for laryngeal cancer, not a diagnostic step.
- Initiating treatment without a definitive histological diagnosis of malignancy would be inappropriate and potentially harmful.
Vocal Cord Paralysis Indian Medical PG Question 9: 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
Vocal Cord Paralysis 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.
Vocal Cord Paralysis Indian Medical PG Question 10: Emergency tracheostomy is not indicated in
- A. Bilateral vocal cord paralysis
- B. Foreign body larynx
- C. Acute severe asthma (Correct Answer)
- D. Stridor due to laryngeal growth
Vocal Cord Paralysis Explanation: ***Acute severe asthma***
- While life-threatening, acute severe asthma is primarily managed with **bronchodilators**, **steroids**, and potentially **non-invasive or invasive ventilation**.
- **Tracheostomy** is generally reserved for situations involving upper airway obstruction that cannot be managed by other means, which is not the primary issue in asthma.
*Bilateral vocal cord paralysis*
- This condition can cause severe **upper airway obstruction** due to the adduction of both vocal cords.
- In an emergency setting, a tracheostomy may be life-saving to bypass the obstructed larynx.
*Foreign body larynx*
- An obstructing **foreign body in the larynx** can lead to immediate and complete airway compromise.
- If efforts like the **Heimlich maneuver** or direct laryngoscopy with removal fail, an emergency tracheostomy might be necessary.
*Stridor due to laryngeal growth*
- A laryngeal growth causing **stridor** indicates significant airway narrowing, which can acutely worsen and lead to respiratory distress.
- In cases of severe or rapidly progressive obstruction, an **emergency tracheostomy** is needed to secure the airway below the level of the growth.
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