Laryngeal Stenosis — MCQs
What is the most appropriate anaesthesia technique for microlaryngoscopy?
Which of the following statements about Laryngomalacia is false?
A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
Which of the following is the best management for radiation induced occlusive disease of carotid artery?
In an infant brought with stridor, diagnosed with laryngomalacia, which of the following is NOT typically observed?
A patient presents with hoarseness of voice and a clinical condition as shown in the image. Identify the lesion:
Inspiratory stridor is due to lesions of:
Laryngitis sicca is associated with ?
Killian's Dehiscence is seen at the level of:
Which part of the larynx is most commonly involved in tuberculosis (TB)?
Laryngeal Stenosis Indian Medical PG Practice Questions and MCQs
Question 1: What is the most appropriate anaesthesia technique for microlaryngoscopy?
- A. Jet ventilation with TIVA
- B. Conventional endotracheal intubation (Correct Answer)
- C. Apneic technique with TIVA
- D. Laryngeal mask airway with spontaneous ventilation
Explanation: ***Conventional endotracheal intubation*** - While other techniques exist, **conventional endotracheal intubation** remains a widely accepted and often preferred method for microlaryngoscopy due to its ability to provide a secure airway, excellent surgical exposure, and controlled ventilation. - This technique allows for adequate **oxygenation and ventilation** during the procedure, which can be prolonged, and it protects the airway from **blood and secretions**. *Jet ventilation with TIVA* - **Jet ventilation** can provide an unobstructed laryngeal view and may be used, but it carries risks such as barotrauma and aspiration, and can cause difficulty with **CO2 clearance**. - While **total intravenous anesthesia (TIVA)** is suitable, the ventilation technique itself may not be the most appropriate primary choice due to its potential complications. *Apneic technique with TIVA* - The **apneic technique** (apneic oxygenation) may offer an unobstructed surgical field but is limited by the duration an individual can be safely apneic without hypercapnia or desaturation and a lack of control over ventilation for longer procedures. - Although **TIVA** is a good anesthetic choice, relying solely on an apneic period for the whole procedure may not be the safest or most practical method for many microlaryngoscopies. *Laryngeal mask airway with spontaneous ventilation* - A **laryngeal mask airway (LMA)** may provide a good view for some laryngeal procedures but does not offer the same level of airway protection against aspiration as an endotracheal tube. - **Spontaneous ventilation** with an LMA might not provide adequate control over gas exchange, especially if the procedure is prolonged or deep anesthesia is required.
Question 2: Which of the following statements about Laryngomalacia is false?
- A. It is the most common congenital anomaly of the larynx.
- B. Stridor disappears when the infant is in a supine position. (Correct Answer)
- C. Symptoms typically manifest many weeks after birth.
- D. Most cases do not require treatment.
Explanation: ***Stridor disappears when the infant is in a supine position.*** - In laryngomalacia, the **omega-shaped epiglottis** and redundant supraglottic tissues **prolapse into the airway** upon inspiration. - The stridor typically **worsens** when the infant is in a **supine position** or crying, as gravity causes further collapse of the airways. *It is the most common congenital anomaly of the larynx.* - **Laryngomalacia** is indeed the **most frequent congenital cause of stridor** in infants. - It results from the **immaturity of the laryngeal cartilages**, leading to their collapse during inspiration. *Symptoms typically manifest many weeks after birth.* - Symptoms of laryngomalacia usually appear in the first few weeks of life, typically around **2-4 weeks post-birth**, and rarely at birth. - This delay is often due to the time it takes for the infant's respiratory efforts to become more vigorous. *Most cases do not require treatment.* - The majority of infants with laryngomalacia have **mild symptoms** that **resolve spontaneously** as the larynx matures, usually by 12 to 18 months of age. - Only a small percentage of severe cases require surgical intervention, such as a **supraglottoplasty**.
Question 3: A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
- A. Acute Laryngotracheobronchitis (Correct Answer)
- B. Acute Bacterial Tracheitis
- C. Acute Epiglottitis
- D. Foreign Body aspiration
Explanation: ***Acute Laryngotracheobronchitis*** - The combination of **low-grade fever** and **stridor** in a 2-year-old child strongly suggests **croup**, which is medically known as acute laryngotracheobronchitis. - Croup is characterized by **inflammation** of the larynx, trachea, and bronchi, often presenting with a **barking cough** and inspiratory stridor. The X-ray image would show the characteristic **steeple sign**. *Acute Bacterial Tracheitis* - This is a more severe bacterial infection that can present with stridor but typically shows **higher fever**, **toxic appearance**, and rapid clinical deterioration. - Unlike croup, bacterial tracheitis patients appear **more ill** and may have **purulent secretions** requiring more aggressive management. *Acute Epiglottitis* - A serious condition characterized by **rapid onset of high fever**, **dysphagia**, drooling, and a **"tripod" position**, which are not indicated by the given symptoms. - The stridor in epiglottitis is typically quieter and may indicate more severe airway obstruction compared to the characteristic stridor of croup. *Foreign Body aspiration* - While foreign body aspiration can cause stridor, it is typically an **acute event** with a sudden onset of choking, coughing, and respiratory distress. - There is no mention of a choking episode or sudden onset, and a low-grade fever is less typical for an uncomplicated foreign body aspiration.
Question 4: Which of the following is the best management for radiation induced occlusive disease of carotid artery?
- A. Carotid endarterectomy
- B. Low dose aspirin
- C. Carotid bypass procedure
- D. Carotid angioplasty and stenting (Correct Answer)
Explanation: ***Carotid angioplasty and stenting*** - **Radiation-induced carotid artery disease** often involves the distal part of the carotid artery, making it less amenable to surgical endarterectomy. - **Angioplasty and stenting** offer a less invasive approach with good technical success in these challenging cases, especially given the increased fragility and fibrosis of radiated tissues. *Carotid endarterectomy* - **Carotid endarterectomy** in previously radiated fields is associated with a significantly higher risk of complications, including **cranial nerve injury**, **wound infection**, and **carotid artery rupture**, due to tissue fibrosis and scarring. - The disease often extends beyond the easily accessible segment for endarterectomy in radiation-induced cases. *Low dose aspirin* - **Low-dose aspirin** is an important component of medical therapy for **atherosclerotic disease** and **stroke prevention**, but it is insufficient as a sole treatment for symptomatic or high-grade occlusive disease of the carotid artery. - It helps manage the underlying **atherosclerotic process** but does not directly address the severe stenosis or occlusion. *Carotid bypass procedure* - **Carotid bypass procedures** are complex surgical interventions usually reserved for cases of **carotid artery occlusion** or **recurrent stenosis** after previous interventions where endarterectomy or stenting is not feasible. - While an option, it is more invasive and technically demanding than angioplasty and stenting, particularly in already radiated tissues with compromised vascular integrity.
Question 5: In an infant brought with stridor, diagnosed with laryngomalacia, which of the following is NOT typically observed?
- A. Stridor will be inspiratory
- B. Hoarseness (Correct Answer)
- C. Prominent arytenoids
- D. Floppy aryepiglottic folds
Explanation: ***Correct: Hoarseness*** - **Laryngomalacia** primarily involves the collapse of supraglottic structures during inspiration, leading to inspiratory stridor - Hoarseness is NOT typically observed because laryngomalacia does **not directly affect the vocal cords** - Hoarseness indicates pathology at the level of the **vocal cords** themselves (such as vocal cord paralysis or inflammation), which is a different entity - The supraglottic collapse in laryngomalacia occurs above the vocal cords, leaving vocal cord function intact *Incorrect: Stridor will be inspiratory* - **Inspiratory stridor** is the hallmark feature of laryngomalacia - The collapse of supraglottic structures during inspiration creates a narrow airway, producing the characteristic high-pitched sound on inhalation - This is the most common presenting symptom in affected infants *Incorrect: Prominent arytenoids* - Laryngoscopy in laryngomalacia often reveals **prominent or redundant arytenoid mucosa** - The collapse of redundant tissue over the arytenoids makes them appear more prominent due to inward movement during inspiration - This contributes to the airway obstruction seen in the condition *Incorrect: Floppy aryepiglottic folds* - **Floppy, shortened aryepiglottic folds** are a hallmark anatomical feature of laryngomalacia - These folds collapse inward during inspiration, obstructing the laryngeal inlet - This collapse is the primary mechanism causing the inspiratory stridor in laryngomalacia
Question 6: A patient presents with hoarseness of voice and a clinical condition as shown in the image. Identify the lesion:
- A. Diphtheria (Correct Answer)
- B. Follicular tonsillitis
- C. Aphthous ulcer
- D. Membranous tonsillitis
Explanation: ***Diphtheria*** - The image shows a **thick, grayish-white pseudomembrane** covering the tonsils and likely extending to other parts of the pharynx, which is a classic sign of diphtheria. - **Hoarseness** indicates laryngeal involvement, a severe complication of diphtheria due to pseudomembrane formation extending to the larynx, potentially causing airway obstruction. *Follicular tonsillitis* - This condition presents with **pus-filled follicles** or spots on the tonsils, which are typically yellow or white, rather than a confluent membrane. - While it causes throat pain and fever, it generally does not lead to the formation of a **firm, adherent pseudomembrane** or significant hoarseness from laryngeal obstruction as seen in diphtheria. *Aphthous ulcer* - An aphthous ulcer is a **small, painful, shallow sore** with a white or yellowish center and a red border, typically found on the non-keratinized oral mucosa. - It does not present as a widespread, thick membranous lesion covering the tonsils and causing hoarseness. *Membranous tonsillitis* - While "membranous tonsillitis" describes the presence of a membrane on the tonsils, this term is often used generally. However, the specific characteristics in the image (thick, grayish, adherent membrane with severe symptoms like hoarseness) are pathognomonic for **diphtheria**. - Other causes of membranous tonsillitis, such as infectious mononucleosis, typically present with a less adherent membrane and often lack the severe systemic toxicity and potential for rapid airway compromise seen in diphtheria.
Question 7: Inspiratory stridor is due to lesions of:
- A. Supraglottis
- B. Trachea
- C. Bronchi
- D. Subglottis (Correct Answer)
Explanation: ***Subglottis*** - **Inspiratory stridor** is classically associated with **subglottic lesions**, such as **croup (laryngotracheobronchitis)** and **subglottic stenosis**. - The **subglottis** is the **narrowest part of the pediatric airway**, making it particularly susceptible to significant obstruction from inflammation or narrowing. - During inspiration, the negative intrathoracic pressure causes **dynamic collapse** of the subglottic region when narrowed, producing characteristic **high-pitched inspiratory stridor**. - Common causes: **Croup**, subglottic stenosis, subglottic hemangioma. *Supraglottis* - Supraglottic lesions (epiglottis, aryepiglottic folds) can also cause **inspiratory stridor**, particularly in **acute epiglottitis**. - However, supraglottic pathology more commonly presents with **muffled voice** (hot potato voice), **dysphagia**, **drooling**, and **tripod positioning**. - The stridor from supraglottic lesions tends to be **lower-pitched** and is often accompanied by more prominent systemic symptoms. *Trachea* - Tracheal lesions typically produce **biphasic stridor** (both inspiratory and expiratory phases) due to fixed obstruction in the main conducting airway. - The trachea is a more rigid structure; obstruction produces a **harsh, lower-pitched** sound heard in both respiratory phases. - Examples: tracheal stenosis, tracheomalacia, tracheal tumors. *Bronchi* - Bronchial lesions cause **expiratory wheezing** rather than stridor, due to dynamic collapse of small airways during exhalation. - Bronchial obstruction affects the lower airways and presents as **polyphonic wheeze** rather than the monophonic sound of stridor.
Question 8: Laryngitis sicca is associated with ?
- A. Rhinosporidium
- B. M. leprae
- C. Klebsiella ozaenae
- D. Klebsiella rhinoscleromatosis (Correct Answer)
Explanation: ***Klebsiella rhinoscleromatis*** - **Laryngitis sicca** is characterized by extreme dryness and crusting of the laryngeal mucosa, which is a known manifestation of complications due to **Rhinoscleroma**. - **Rhinoscleroma** is a chronic granulomatous disease caused by *Klebsiella rhinoscleromatis* (formerly *K. rhinoscleromatosis*), primarily affecting the upper respiratory tract including the larynx. *Rhinosporidium* - **Rhinosporidium seeberi** is an aquatic protistan parasite that causes **rhinosporidiosis**, characterized by friable, polypoidal lesions, often in the nose, but typically not laryngitis sicca. - The lesions caused by Rhinosporidium are usually vascular and bleeding, rather than dry and crusting. *M. leprae* - **Mycobacterium leprae** is the causative agent of **leprosy**, a chronic infectious disease primarily affecting the skin, peripheral nerves, upper respiratory tract mucosa, eyes, and testes. - While *M. leprae* can affect the larynx, it typically causes **granulomatous infiltration** and nodule formation leading to hoarseness and stridor, not specifically laryngitis sicca. *Klebsiella ozaenae* - *Klebsiella ozaenae* is associated with **ozena**, a form of chronic atrophic rhinitis characterized by a foul odor, crusting, and atrophy of nasal mucosa. - While it causes dryness and crusting, its primary manifestation is in the **nasal cavity**, and it is not directly linked to laryngitis sicca in the context tested here.
Question 9: Killian's Dehiscence is seen at the level of:
- A. Inferior Constrictor (Correct Answer)
- B. Superior Constrictor
- C. Middle constrictor
- D. Thyroepiglottic
Explanation: ***Inferior Constrictor*** - **Killian's dehiscence** is a triangular area of weakness in the posterior pharyngeal wall, located between the **thyropharyngeal** and **cricopharyngeal** parts of the inferior constrictor muscle. - This anatomical weakness is a common site for the formation of a **Zenker's diverticulum**. *Superior Constrictor* - The superior constrictor muscle is located higher up in the pharynx and is not associated with Killian's dehiscence. - Its weakness is related to **Passavant's ridge**, which is important for speech and swallowing, not Zenker's diverticulum. *Middle constrictor* - The middle constrictor muscle is positioned between the superior and inferior constrictors, and there is no specific dehiscence named after it associated with diverticula. - Its function primarily involves constricting the pharynx during swallowing. *Thyroepiglottic* - The thyroepiglottic is a muscle of the **larynx**, not the pharynx, and it is involved in vocal fold tension and airway protection. - It does not contribute to the structure of the pharyngeal wall or the formation of Killian's dehiscence.
Question 10: Which part of the larynx is most commonly involved in tuberculosis (TB)?
- A. Anterior
- B. Posterior (Correct Answer)
- C. Middle
- D. Anywhere
Explanation: ***Posterior*** - The **posterior larynx**, specifically the **arytenoids** and **interarytenoid area**, is the most common site for tuberculosis involvement. - This region is susceptible due to its rich **lymphatic supply** and direct exposure to infected secretions from the lungs. *Anterior* - While TB can affect any part of the larynx, the **anterior laryngeal structures** are less frequently the primary site of involvement. - The vocal cords, which are in the anterior-middle aspect, are less commonly affected initially compared to the posterior structures. *Middle* - The middle part of the larynx, including the **vocal cords**, is not the predominant site for initial tuberculous lesions. - Involvement here often occurs as the disease progresses from more commonly affected areas. *Anywhere* - Although TB can theoretically affect any part of the larynx, it demonstrates a strong predilection for the **posterior laryngeal region**. - Stating "anywhere" does not accurately reflect the statistically significant preference for specific anatomical sites.
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