Diseases of the Larynx Practice Questions

Q: A 58-year-old man, chronic smoker, presents with progressive hoarseness of voice and throat discomfort for 4 months. Laryngoscopy reveals a laryngeal growth, and neck examination shows a single ipsilateral, mobile cervical lymph node. Biopsy confirms squamous cell carcinoma of the larynx. What is the most appropriate treatment?

Chemoradiotherapy. ***Chemoradiotherapy*** * For locally advanced laryngeal cancer or cases with nodal involvement (N1), organ preservation protocols using **concurrent chemoradiotherapy** are the standard of care. * This approach is preferred for patients capable of tolerating intensive therapy to avoid the functional morbidity associated with total laryngectomy, while maintaining comparable survival rates. *Radiotherapy alone* * While radiotherapy is a viable option for early-stage (T1/T2) laryngeal cancer, it is insufficient for advanced or N-positive cases. * In cases with nodal involvement, adding chemotherapy improves locoregional control and patient survival compared to radiation alone. *Partial laryngectomy* * This procedure is generally reserved for small, localized lesions (usually early T-stage) where the tumor is confined to a specific part of the larynx. * It is unsuitable for patients with significant nodal involvement, which requires a more comprehensive approach typically involving systemic therapy. *Total laryngectomy* * Reserved for advanced T4 tumors, salvage therapy after recurrence, or patients unfit for organ preservation protocols. * Since the tumor is potentially responsive to non-surgical organ preservation strategies, committing the patient to the permanent loss of the voice box is not the first-line intervention.

Q: A chronic smoker presents with a low -pitched, husky voice. Indirect laryngoscopy reveals findings as shown in the image. What is the most likely diagnosis?

Reinke’s edema. ***Reinke's edema*** - This condition is strongly associated with **chronic smoking** and presents classically as **bilateral, gelatinous swelling** of the **superficial lamina propria** of the vocal cords. - It results in the characteristic **low-pitched, husky voice** (dysphonia) due to increased mass of the vocal folds, which is pathognomonic when seen on laryngoscopy. *Vocal cord polyp* - Usually presents as a **unilateral** lesion, often related to acute trauma or **vocal abuse** rather than chronic smoking alone. - These lesions are typically more **localized** and pedunculated or sessile rather than the diffuse, sausage-like swelling seen in Reinke's. *Bilateral vocal cord cyst* - Cysts are typically **non-smoker related** and arise from **ductal obstruction** of mucus-secreting glands in the vocal cord. - They appear as discrete, **fluid-filled swellings** beneath the epithelium, appearing distinct from the diffuse, grayish edema characteristic of Reinke's. *Laryngeal papillomatosis* - This condition is caused by **Human Papillomavirus (HPV)** and typically presents as multiple **wart-like, friable growths** on the vocal cords. - It is generally seen in younger patients (children or young adults) and manifests with progressive **hoarseness** and potential **airway obstruction**.

Q: A 12-year-old child presents with a midline neck swelling that moves upward with deglutition. She undergoes surgical removal, and postoperatively, she cannot raise her voice. What is the most likely nerve injury?

Unilateral superior laryngeal nerve palsy. ***Unilateral superior laryngeal nerve palsy*** - The **external branch of the superior laryngeal nerve** (SLN) supplies the **cricothyroid muscle**, which is responsible for tensioning the vocal cords to produce high-pitched sounds. - Injury to this nerve during the excision of a **thyroglossal duct cyst** or thyroid surgery leads to difficulty in producing high-pitched tones and **vocal fatigue**. *Bilateral recurrent laryngeal nerve palsy* - Bilateral injury to the **recurrent laryngeal nerve** (RLN) typically results in **stridor** and **respiratory distress** due to the vocal cords remaining adducted in the paramedian position. - The primary deficit is airway compromise rather than a selective loss of vocal pitch. *Hypoglossal nerve injury* - The **hypoglossal nerve** (CN XII) innervates the muscles of the tongue, and its injury results in **tongue deviation** toward the side of the lesion and potential **dysarthria**. - It is located superiorly to the cricothyroid area and is not typically injured during the surgical excision of a midline thyroglossal duct cyst. *Vagus nerve injury* - Injury to the **vagus nerve** (CN X) higher up in its course would present with a broad array of symptoms, including **palatal paralysis** and **absent gag reflex**. - This injury is highly unlikely during a localized neck surgery for a thyroglossal duct cyst.

Q: Which of the following is NOT used in the treatment of Juvenile Laryngeal Papillomatosis?

Interferon beta (INF β). **Explanation:** Juvenile Laryngeal Papillomatosis (JLP), caused by **HPV types 6 and 11**, is characterized by recurrent benign epithelial tumors. The primary treatment is surgical debulking (CO2 laser or microdebrider), but adjuvant medical therapy is indicated when the disease is aggressive (requiring >4 surgeries per year). **Why Option B is Correct:** **Interferon beta (INF β)** is not a standard treatment for JLP. While Interferons have antiviral and antiproliferative properties, clinical evidence and established protocols specifically utilize **Interferon alpha (INF α)**. INF β does not have a proven role in the management of this condition. **Analysis of Incorrect Options:** * **Interferon alpha (INF α):** Historically the first-line adjuvant therapy. It slows the rate of recurrence by inducing antiviral states in cells, though it rarely provides a permanent cure and has significant side effects (flu-like symptoms, growth retardation). * **Cidofovir:** A potent antiviral (cytosine nucleotide analog) administered via **intralesional injection**. It is currently one of the most commonly used adjuvant agents for recalcitrant cases. * **Bevacizumab:** An anti-VEGF monoclonal antibody. It is a newer, highly effective treatment (administered systemically or intralesionally) that inhibits the angiogenesis required for papilloma growth. **High-Yield Clinical Pearls for NEET-PG:** * **Most common benign tumor** of the larynx in children. * **Triad of symptoms:** Hoarseness (most common), stridor, and respiratory distress. * **Diagnosis:** Direct laryngoscopy shows "cauliflower-like" masses. * **Gold Standard Adjuvant:** Cidofovir (Intralesional). * **Newer Trend:** Bevacizumab is increasingly preferred for severe cases. * **Note:** Tracheostomy should be avoided as it may lead to "stomal seeding" of the papilloma.

Q: What is the standard treatment for T1N0M0 laryngeal cancer?

Radiotherapy. **Explanation:** The management of early-stage laryngeal cancer (T1N0M0) focuses on **organ preservation** and maintaining voice quality. For T1 lesions, both **Radiotherapy (RT)** and **Endoscopic CO2 Laser Excision** are considered standard treatments, as they offer similar local control and survival rates (approx. 90-95%). **Why Radiotherapy is the Correct Answer:** In the context of standard examinations like NEET-PG, **Radiotherapy** is traditionally favored as the primary answer for T1 glottic lesions because it provides an excellent functional outcome with a superior voice quality compared to surgery. It treats the entire larynx, addressing potential multicentricity of the disease without the need for surgical margins. **Analysis of Incorrect Options:** * **B. Total Laryngectomy:** This is a radical procedure reserved for advanced stages (T3 or T4) where the larynx is non-functional or there is extensive cartilage destruction. It is never the first-line treatment for T1 disease. * **C. Laser Therapy:** While highly effective and increasingly popular (Transoral Laser Microsurgery - TLM), it is often considered an alternative to RT. In many textbooks, RT remains the "classic" gold standard for voice preservation in T1. * **D. Microlaryngoscopic Surgery:** While used for biopsy or very superficial "stripping," it is generally insufficient as a standalone curative treatment for invasive T1 cancer unless performed via CO2 laser (TLM). **Clinical Pearls for NEET-PG:** * **T1a:** Involves one vocal cord; **T1b:** Involves both vocal cords. * **Voice Quality:** RT generally offers a better "smooth" voice, whereas Laser surgery may result in a "breathy" or "rough" voice due to tissue loss. * **Salvage:** If RT fails, surgery (Partial or Total Laryngectomy) can still be performed. * **Treatment of Choice for T3/T4:** Concurrent Chemoradiotherapy (for organ preservation) or Total Laryngectomy.

Q: End tracheostomy is performed in patients undergoing surgery for which of the following conditions?

Laryngectomy. **Explanation:** **1. Why Laryngectomy is Correct:** An **End Tracheostomy** (also known as a permanent tracheostomy) is performed when the entire larynx is surgically removed (Total Laryngectomy). In this procedure, the distal tracheal stump is brought out to the skin of the neck and sutured to the margins of the skin incision. This creates a permanent stoma where the airway is completely separated from the pharynx and esophagus. Since the larynx (the connection between the upper and lower airway) is gone, the patient breathes exclusively through this stoma for the rest of their life. **2. Why Other Options are Incorrect:** * **Laryngofissure surgery:** This is a thyrotomy where the larynx is opened to access the vocal cords. It usually requires a **temporary/prolonged tracheostomy** to maintain the airway during postoperative edema, but the larynx remains intact. * **Oropharyngeal growth:** These patients may require a **temporary tracheostomy** to bypass an upper airway obstruction or for anesthesia access, but the tracheal opening is not permanent. * **Obstructive Sleep Apnea (OSA) with stridor:** Tracheostomy is a treatment of last resort for OSA. It is a **temporary/permanent-in-situ** tracheostomy (the larynx is preserved), not an "End" tracheostomy. **3. Clinical Pearls for NEET-PG:** * **End vs. Side Tracheostomy:** In an "End" tracheostomy, the trachea is severed and the end is brought to the skin. In a standard "Side" tracheostomy, an opening is made in the anterior wall of the trachea while the rest of the airway remains in continuity. * **Post-Laryngectomy:** Because the airway and food passage are separated, these patients **cannot aspirate** through the stoma, but they also cannot perform a Valsalva maneuver effectively. * **High-Yield Fact:** The most common indication for Total Laryngectomy (and thus End Tracheostomy) is advanced (T3/T4) Squamous Cell Carcinoma of the larynx.

Q: Mild hoarseness with stridor is seen in:

Bilateral abductor palsy. ### Explanation The clinical presentation of **Bilateral Abductor Palsy** (usually due to injury to both recurrent laryngeal nerves) is characterized by the vocal cords being fixed in the **median or paramedian position**. 1. **Why the correct answer is right:** In bilateral abductor palsy, the vocal cords cannot move away from the midline. Because the cords are positioned very close to each other, the **glottic airway is severely compromised**, leading to inspiratory **stridor**. However, because the cords are in a near-normal position for phonation (close together), the **voice remains remarkably good or only mildly hoarse**. This "good voice but poor airway" paradox is a classic diagnostic hallmark. 2. **Why the incorrect options are wrong:** * **Unilateral abductor palsy:** Usually presents with mild hoarseness or breathiness, but the unaffected cord compensates. Stridor is typically absent because the airway remains adequate. * **Laryngomalacia:** The most common cause of congenital stridor. It presents with an inspiratory "crowing" sound that improves when the infant is prone. Hoarseness is not a feature as the vocal cords function normally. * **Tracheal stenosis:** Presents with biphasic stridor and dyspnea. Since the pathology is below the level of the larynx, the voice is typically normal unless there is associated glottic involvement. ### Clinical Pearls for NEET-PG: * **Most common cause** of bilateral abductor palsy: Thyroid surgery (injury to bilateral Recurrent Laryngeal Nerves). * **Management:** Emergency tracheostomy is often required to secure the airway, followed by permanent procedures like lateralization of the cord (Woodman’s operation) or posterior cordotomy. * **Semon’s Law:** States that in progressive lesions of the recurrent laryngeal nerve, the abductor fibers are affected before the adductor fibers.

Q: For foreign bodies retained in the larynx causing choking, what is the first-line management?

Heimlich maneuver. **Explanation:** The **Heimlich maneuver** (subdiaphragmatic abdominal thrusts) is the gold-standard first-line emergency management for an upper airway obstruction caused by a foreign body. The physiological principle is to create an **"artificial cough"** by elevating the diaphragm, which increases intrathoracic pressure and forces air out of the lungs to expel the obstructing object. **Analysis of Options:** * **Heimlich Maneuver (Correct):** It is non-invasive, requires no equipment, and is the immediate step for a conscious choking victim. * **Airway Intubation (Incorrect):** Intubation is technically difficult or impossible if a foreign body is physically blocking the laryngeal inlet. Attempting it may push the object further down. * **Heimlich Valve (Incorrect):** This is a one-way valve used in the management of a pneumothorax to allow air to exit the pleural space; it has no role in airway obstruction. * **Tracheostomy (Incorrect):** While it provides a definitive surgical airway, it is time-consuming and considered only if non-invasive maneuvers (Heimlich) and basic life support (cricothyroidotomy) fail. **High-Yield Clinical Pearls for NEET-PG:** * **In Infants (<1 year):** Abdominal thrusts are contraindicated due to the risk of liver injury. Use **5 back blows and 5 chest thrusts** instead. * **In Pregnant/Obese Patients:** Use **chest thrusts** (lower sternum) instead of abdominal thrusts. * **Unconscious Patient:** If the patient becomes unresponsive, start **CPR** immediately. The chest compressions serve the dual purpose of circulating blood and providing pressure to dislodge the foreign body. * **Gold Standard Investigation:** For a stable patient with suspected foreign body inhalation, **Rigid Bronchoscopy** is the investigation and treatment of choice.

Q: A middle-aged male presents with a 2-year history of hoarseness and a 30-year smoking history. Examination reveals a reddish area of mucosal irregularity over a portion of both vocal cords. Which of the following is NOT indicated in the management?

Bilateral cordectomy. ### Explanation The clinical presentation describes **Vocal Cord Leukoplakia/Erythroplakia**, which are premalignant lesions (keratosis with dysplasia) often associated with chronic irritation from smoking. #### Why "Bilateral Cordectomy" is NOT indicated: A **cordectomy** (excision of the vocal cord) is a radical surgical procedure used for confirmed early-stage laryngeal malignancy (T1a glottic cancer). Performing a bilateral cordectomy for a lesion that has not yet been histologically confirmed as invasive cancer is inappropriate. Furthermore, bilateral cordectomy results in severe, permanent dysphonia and potential airway compromise due to scarring (web formation), making it an overly aggressive and incorrect initial management step. #### Analysis of Other Options: * **Cessation of smoking:** This is the most critical conservative step. Smoking is the primary etiological factor; stopping it can sometimes lead to the regression of dysplastic changes. * **Microlaryngeal surgery (MLS) for biopsy:** This is the **gold standard for diagnosis**. Any suspicious mucosal irregularity must be biopsied to rule out invasive squamous cell carcinoma and to grade the degree of dysplasia. * **Regular follow-up:** Premalignant lesions of the larynx carry a significant risk of transformation into carcinoma. Even after biopsy or excision, close surveillance is mandatory to detect recurrence or progression. #### NEET-PG High-Yield Pearls: * **Pre-cancerous lesions of Larynx:** Leukoplakia (white patch), Erythroplakia (red patch), and Chronic Hypertrophic Laryngitis. * **Management Protocol:** Stop irritants (smoking/alcohol) → MLS with excisional biopsy (stripping of the vocal cord) → Histopathological examination → Long-term follow-up. * **Cordectomy Indications:** Primarily indicated for **T1a Squamous Cell Carcinoma** of the glottis. It is never the first step for unconfirmed mucosal irregularities.

Question 1

A 58-year-old man, chronic smoker, presents with progressive hoarseness of voice and throat discomfort for 4 months. Laryngoscopy reveals a laryngeal growth, and neck examination shows a single ipsilateral, mobile cervical lymph node. Biopsy confirms squamous cell carcinoma of the larynx. What is the most appropriate treatment?

Accepted Answer

Chemoradiotherapy

Answer

Radiotherapy alone

Answer

Partial laryngectomy

Answer

Total laryngectomy

Question 2

A chronic smoker presents with a low -pitched, husky voice. Indirect laryngoscopy reveals findings as shown in the image. What is the most likely diagnosis?

Accepted Answer

Reinke’s edema

Answer

Vocal cord polyp

Answer

Bilateral vocal cord cyst

Answer

Laryngeal papillomatosis

Question 3

A 12-year-old child presents with a midline neck swelling that moves upward with deglutition. She undergoes surgical removal, and postoperatively, she cannot raise her voice. What is the most likely nerve injury?

Accepted Answer

Unilateral superior laryngeal nerve palsy

Answer

Bilateral recurrent laryngeal nerve palsy

Answer

Hypoglossal nerve injury

Answer

Vagus nerve injury

Question 4

Which of the following is NOT used in the treatment of Juvenile Laryngeal Papillomatosis?

Accepted Answer

Interferon beta (INF β)

Answer

Interferon alpha (INF α)

Answer

Bevacizumab

Answer

Cedofovir

Question 5

What is the standard treatment for T1N0M0 laryngeal cancer?

Accepted Answer

Radiotherapy

Answer

Total laryngectomy

Answer

Laser therapy

Answer

Microlaryngoscopic surgery

Question 6

End tracheostomy is performed in patients undergoing surgery for which of the following conditions?

Accepted Answer

Laryngectomy

Answer

Laryngofissure surgery

Answer

Oropharyngeal growth

Answer

Obstructive sleep apnea with stridor

Question 7

Mild hoarseness with stridor is seen in:

Accepted Answer

Bilateral abductor palsy

Answer

Unilateral abductor palsy

Answer

Laryngomalacia

Answer

Tracheal stenosis

Question 8

For foreign bodies retained in the larynx causing choking, what is the first-line management?

Accepted Answer

Heimlich maneuver

Answer

Airway intubation

Answer

Heimlich valve

Answer

Tracheostomy

Question 9

A middle-aged male presents with a 2-year history of hoarseness and a 30-year smoking history. Examination reveals a reddish area of mucosal irregularity over a portion of both vocal cords. Which of the following is NOT indicated in the management?

Accepted Answer

Bilateral cordectomy

Answer

Cessation of smoking

Answer

Microlaryngeal surgery for biopsy

Answer

Regular follow-up

Question 10

A 75-year-old thin cachectic woman undergoes a tracheostomy for failure to wean from the ventilator. One week later, she develops significant bleeding from the tracheostomy. Which of the following would be an appropriate initial step in the management of this problem?

Accepted Answer

Attempt to reintubate the patient with an endotracheal tube.

Answer

Remove the tracheostomy and place pressure over the wound.

Answer

Deflate the balloon cuff on the tracheostomy.

Answer

Upsize the tracheostomy.

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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