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?

Direct laryngoscopy with biopsy

During thyroidectomy, which nerve, if damaged, can cause a hoarse voice?

Recurrent laryngeal; loops under aorta/subclavian

Superior laryngeal; with superior thyroid artery

Glossopharyngeal; along posterior thyroid

Hypoglossal; inferior to thyroid

Which of the following statements about laryngomalacia is true?

It typically presents with inspiratory stridor.

It is characterized by an omega-shaped epiglottis.

It requires immediate surgical intervention.

It always requires surgical intervention in newborns.

The image shows which of the following tests being performed? (Recent NEET Pattern 2016-17)

A= Indirect laryngoscopy, B= Spatula test

A= Posterior rhinoscopy, B= Spatula test

A= Direct laryngoscopy, B= Spatula test

A= Anterior rhinoscopy, B= Spatula test

Dysphonia for INI-CET: High-Yield ENT Lessons

Dysphonia Defined - Hoarse Whisperings

Dysphonia: Any abnormality in voice quality (e.g., hoarse, breathy, strained).
Larynx Anatomy Essentials:
- Cartilages: Thyroid, cricoid, arytenoids (paired), epiglottis.
- Intrinsic Muscles:
  - Thyroarytenoid (Vocalis): Body of vocal fold; shortens/relaxes (tensor/adductor).
  - Posterior Cricoarytenoid (PCA): Sole abductor. 📌 PCA: 'Party Cord Opener'.
  - Others: Lateral cricoarytenoid, interarytenoid (adductors); Cricothyroid (tensor, SLN).
- Nerve Supply:
  - Recurrent Laryngeal Nerve (RLN): All intrinsic muscles except cricothyroid; sensory below vocal cords.
  - Superior Laryngeal Nerve (SLN): External branch (motor to cricothyroid); Internal branch (sensory above vocal cords).
Physiology of Phonation:
- Myoelastic-Aerodynamic Theory: Vocal fold vibration results from a balance of muscle tension (myoelastic properties) and aerodynamic forces (Bernoulli effect of exhaled air).

Laryngeal cartilages, muscles, and vocal folds

⭐ The posterior cricoarytenoid (PCA) muscle is the sole abductor of the vocal cords, innervated by the recurrent laryngeal nerve (RLN).

Etiology Spectrum - Why So Hoarse?

Organic Causes:
- Inflammatory: Acute/Chronic Laryngitis
- Structural: Nodules, Polyps, Cysts, Reinke's, Granuloma, Sulcus, Web, Cancer
- Traumatic: Intubation/External trauma
Functional Causes:
- Muscle Tension Dysphonia (MTD)
- Puberphonia
- Psychogenic Dysphonia/Aphonia
Neurological Causes:
- Vocal Cord Palsy (RLN/SLN)
- Spasmodic Dysphonia
- Parkinson's, Myasthenia
Systemic Causes:
- Hypothyroidism
- LPRD

Vocal cord lesions: nodules, polyp, and cyst

Feature	Vocal Nodules	Vocal Polyps	Vocal Cysts
Location	Bilateral, Ant 1/3-Post 2/3 jnct.	Unilateral (usu.), mid-membranous fold	Unilateral, in SLP
Etiology	Chronic voice abuse	Acute voice abuse/trauma	Mucous gland block/congenital
Appearance	Small, white, callous	Lg, red/pale, gelatinous/hemorrhagic	Submucosal, yellow/white, rnd
Voice Quality	Breathy, hoarse, effortful	Hoarse, diplophonia, breathy	Hoarse, diplophonia (size-dep.)

Clinical Approach - Unmasking Dysphonia

History Taking:

Onset (sudden/gradual), duration (acute <3 weeks, chronic >3 weeks), progression.
Severity: GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) 📌.
Associated: Odynophonia, dysphagia, stridor, cough, globus.
Vocal habits, occupation, smoking/alcohol. Hoarseness >3 weeks warrants laryngoscopy.

Red Flags for Malignancy:

Symptom/Sign	Note
Persistent Hoarseness	Esp. smokers, >3 wks
Unexplained Weight Loss	Systemic sign
Hemoptysis	Bleeding
Neck Mass	Metastasis
Referred Otalgia	Nerve involvement

Voice: Quality, pitch, loudness.
Laryngeal Exam:
- IDL.
- FNPLS (gold standard).
- Videostroboscopy (mucosal wave).
Neck Palpation.

Flexible Laryngoscopy and Vocal Cord Oscillation

⭐ Videostroboscopy is crucial for differentiating benign vocal fold lesions like cysts from nodules or polyps by assessing the mucosal wave, which is typically reduced or absent over a cyst.

Common Culprits - Vocal Villains

Acute Laryngitis: Viral. Hoarseness. Mgt: Voice rest, hydration.
Vocal Nodules: Voice abuse. Bilateral, 'singer's nodes'. Mgt: Voice therapy; surgery if refractory.
Vocal Polyps: Voice abuse/trauma. Unilateral. Mgt: Voice therapy, microlaryngeal surgery.
Reinke's Edema: Smoking, 'smoker's voice'. Bilateral diffuse swelling. Mgt: Smoking cessation, voice therapy, surgery.
Vocal Cord Paralysis: Iatrogenic (thyroidectomy), malignancy, idiopathic.
- Unilateral: Breathy voice, aspiration risk.
- Bilateral: Stridor, airway emergency.
- Invx: CT. Mgt: Voice therapy, injection, thyroplasty.
Laryngeal Carcinoma: Risks: Smoking, alcohol. Persistent hoarseness. Early glottic: good prognosis.

Feature	Acute Laryngitis	Vocal Nodules	Vocal Polyps	Reinke's Edema
Etiology	Viral	Voice abuse	Voice abuse/trauma	Smoking
Laterality	Bilateral	Bilateral	Unilateral	Bilateral
Key Feature	Inflammation	'Singer's nodes'	Sessile/pedunc.	'Smoker's voice'
Mgt (Prim.)	Voice rest	Voice therapy	Voice Rx/Surgery	Stop smoking

⭐ The most common cause of iatrogenic unilateral vocal cord paralysis is thyroid surgery due to recurrent laryngeal nerve injury.

High‑Yield Points - ⚡ Biggest Takeaways

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Dysphonia