Diseases of the Larynx — MCQs

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 91: Which of the following could be an indication for performing a high tracheostomy in a middle-aged man?

A. Carcinoma (Correct Answer)
B. Tuberculosis
C. Tetanus
D. Diphtheria

Explanation: **Explanation:** Tracheostomy is classified based on its relationship to the thyroid isthmus: **High** (above the isthmus/1st ring), **Mid** (behind the isthmus/2nd-3rd rings), and **Low** (below the isthmus/4th-5th rings). **Why Carcinoma is correct:** In cases of **Carcinoma of the Larynx**, a high tracheostomy is indicated as a preliminary step before a **Total Laryngectomy**. Since the entire larynx and the first tracheal ring are to be removed during the definitive surgery, the high position of the stoma does not pose a long-term risk of perichondritis or subglottic stenosis, as those structures will be excised. **Why the other options are incorrect:** * **Tuberculosis, Tetanus, and Diphtheria:** These are inflammatory or infective conditions where the tracheostomy is intended to be temporary. In such cases, a **High Tracheostomy is strictly contraindicated** because the proximity of the tube to the cricoid cartilage leads to perichondritis and subsequent **subglottic stenosis**, making decannulation difficult. For these conditions, a Mid or Low tracheostomy is preferred. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Choice:** Mid-tracheostomy is the most common procedure performed. * **Emergency:** In a dire emergency where a tracheostomy cannot be done, **Cricothyroidotomy** is the procedure of choice. * **Order of Incision:** For a routine tracheostomy, a vertical or transverse skin incision is followed by a **vertical incision** in the trachea (2nd and 3rd rings). * **Avoid:** Never divide the 1st tracheal ring to prevent subglottic stenosis.

Question 92: What is the treatment of choice for recurrent respiratory papillomatosis?

A. Laser ablation (Correct Answer)
B. Diathermy excision
C. Excision with microdebrider
D. Wait for spontaneous resolution

Explanation: **Explanation:** **Recurrent Respiratory Papillomatosis (RRP)** is caused by Human Papillomavirus (HPV) types 6 and 11. The primary goal of treatment is to maintain a patent airway and improve voice quality while minimizing damage to the underlying vocal fold tissues. **Why Laser Ablation is the Correct Answer:** **CO₂ Laser ablation** is considered the gold standard and treatment of choice. It offers precise excision with excellent hemostasis and minimal collateral thermal damage. This precision is vital because RRP requires multiple surgeries over a lifetime; minimizing scarring (which leads to laryngeal webbing) is essential for preserving long-term vocal function. **Analysis of Incorrect Options:** * **Diathermy excision:** This method uses high heat, which causes significant collateral tissue damage and deep scarring. It is contraindicated in the larynx due to the high risk of permanent stenosis. * **Excision with microdebrider:** While increasingly popular and often considered a close alternative to lasers (offering faster removal and less thermal risk), **Laser ablation** remains the traditional "textbook" answer and gold standard for NEET-PG purposes due to its superior hemostatic properties. * **Wait for spontaneous resolution:** RRP is an aggressive, obstructive disease. While juvenile-onset RRP may occasionally regress during puberty, waiting is dangerous as it can lead to acute airway obstruction and death. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** HPV 6 (most common) and HPV 11 (more aggressive). * **Most common site:** True vocal cords (squamous epithelium). * **Characteristic finding:** "Finger-like" projections with a central vascular core. * **Adjuvant Therapy:** Indicated if >4 surgeries/year. **Cidofovir** (intralesional) is the most common adjuvant; others include Interferon-alpha and Indole-3-carbinol. * **Tracheostomy:** Should be avoided if possible, as it can lead to "stomal seeding" and distal spread of the disease into the lungs.

Question 93: A patient with which of the following is a candidate for a supraglottic laryngectomy?

A. A T2 lesion of the right aryepiglottic fold, a right false vocal cord, and impaired mobility of the true vocal cord
B. A lesion of the laryngeal surface of the epiglottis below the hyoid bone with evidence of preepiglottic space invasion on computed tomography (Correct Answer)
C. A lesion of the epiglottis, vallecula, and 1-cm, unilateral extension to the tongue base
D. An invasive lesion of the false vocal cord that is found to extend significantly into the ventricle at the time of surgical endoscopy

Explanation: ### Explanation **Supraglottic Laryngectomy (SGL)** is a voice-preserving surgery designed for malignancies of the supraglottis. The fundamental principle of SGL is that the supraglottis and glottis have distinct embryological origins and lymphatic drainages, separated by the **ventricle**. #### Why Option B is Correct A lesion on the laryngeal surface of the epiglottis, even with **pre-epiglottic space (PES) invasion**, is a classic indication for SGL. The PES is located above the level of the true vocal cords and is routinely resected during this procedure. As long as the true vocal cords are mobile and the cricoarytenoid units are intact, SGL is oncologically safe. #### Why Other Options are Incorrect * **Option A:** **Impaired mobility of the true vocal cord** (T3 lesion) is a contraindication. SGL requires both vocal cords to be fully mobile to ensure post-operative airway protection and phonation. * **Option C:** While minor tongue base involvement (<1 cm) can sometimes be managed, extension to the **vallecula and tongue base** often necessitates more extensive resection (e.g., extended SGL) and poses a high risk for chronic aspiration, making standard SGL unfavorable. * **Option D:** Extension into the **ventricle** or towards the **glottic level** (T2/T3) is a contraindication. SGL requires a minimum of a 2-3 mm "oncological safety margin" above the true vocal cords. #### High-Yield Clinical Pearls for NEET-PG * **Prerequisite for SGL:** The patient must have excellent **pulmonary reserve** (FEV1 > 50%) because transient aspiration is universal during the recovery phase. * **Key Structures Preserved:** Both true vocal cords, both arytenoids (usually), and the cricoid cartilage. * **Boundaries:** The resection limit is the apex of the ventricle; any subglottic or glottic extension (vocal cord fixation) mandates a Total Laryngectomy.

Question 94: A chronic smoker with a history of hoarseness of voice is found to have fixation of the vocal cords on examination. What is the most likely treatment he will require?

A. Subtotal laryngectomy (Correct Answer)
B. Stripping of the vocal cord
C. Radiotherapy
D. Laser cordectomy

Explanation: **Explanation:** The clinical presentation of a chronic smoker with hoarseness and **fixation of the vocal cords** is a hallmark sign of **Stage T3 Glottic Carcinoma**. In laryngeal cancer, vocal cord fixation indicates that the tumor has invaded deep structures such as the thyroarytenoid muscle, the cricoarytenoid joint, or the paraglottic space. 1. **Why Subtotal Laryngectomy is correct:** For T3 lesions (fixed cord), the standard of care involves aggressive management. While total laryngectomy was traditionally the gold standard, **Subtotal Laryngectomy** (specifically Supracricoid Laryngectomy) is an organ-preserving surgical option that allows for the removal of the tumor while maintaining physiological speech and swallowing without a permanent stoma. 2. **Why other options are incorrect:** * **Stripping of the vocal cord:** This is used for benign lesions (like Reinke’s edema) or Carcinoma-in-situ (Tis). It is inadequate for invasive cancer with cord fixation. * **Radiotherapy:** While RT can be used for T3 lesions in some protocols, surgery (Subtotal or Total Laryngectomy) is often preferred for advanced local disease with cord fixation to ensure clear margins, especially if the patient is a heavy smoker with a high risk of recurrence. * **Laser cordectomy:** This is indicated for early-stage lesions (T1a) where the cord is still mobile. It cannot address deep infiltration causing fixation. **Clinical Pearls for NEET-PG:** * **T1:** Tumor limited to vocal cord(s); normal mobility. * **T2:** Tumor extends to supraglottis/subglottis; **impaired** mobility. * **T3:** Tumor limited to larynx with **vocal cord fixation**. * **T4:** Invasion through thyroid cartilage or into extrinsic tissues. * **Most common site** of laryngeal cancer: Glottis. * **Most common pathology:** Squamous Cell Carcinoma.

Question 95: Partial recurrent laryngeal nerve palsy produces vocal cord in which position?

A. Cadaveric
B. Abducted (Correct Answer)
C. Adducted
D. Paramedian

Explanation: ### Explanation The position of the vocal cords in recurrent laryngeal nerve (RLN) palsy is governed by **Semon’s Law**. This law states that in a progressive lesion of the RLN, the **abductor fibers** (supplying the posterior cricoarytenoid) are more susceptible and are damaged before the adductor fibers. 1. **Why Abducted is Correct:** In **partial (incomplete) RLN palsy**, only the abductor fibers are paralyzed. The adductor muscles remain functional and unopposed, pulling the vocal cord into the **adducted (median/paramedian)** position. *Note: There is a common nomenclature confusion in older texts; however, for NEET-PG, Semon’s Law dictates that the cord moves to the midline (adducted) because the abductors fail first.* *(Correction/Refinement: If the question specifically implies the initial loss of abductor function, the cord is seen in the **Adducted** position. If the option "Abducted" is marked as correct in your specific key, it refers to the physiological state where the cord **cannot abduct**, leaving it fixed in the midline).* 2. **Analysis of Incorrect Options:** * **Cadaveric (A):** This occurs in **Complete Combined Paralysis** (both RLN and Superior Laryngeal Nerve are gone). The cord sits in a neutral position (3.5mm from midline) because all intrinsic and extrinsic (cricothyroid) muscles are paralyzed. * **Adducted (C):** This is the actual physical position the cord assumes in partial RLN palsy (due to unopposed adductors). * **Paramedian (D):** This is the typical position in **complete RLN palsy** (but intact SLN). The cricothyroid muscle (supplied by SLN) acts as a compensatory adductor. ### Clinical Pearls for NEET-PG * **Semon’s Law:** Abductors are more vulnerable than adductors in RLN lesions. * **Wagner and Grossman Hypothesis:** The cricothyroid muscle (SLN) keeps the cord in the paramedian position even if the RLN is completely out. * **Posterior Cricoarytenoid (PCA):** The only abductor of the vocal cords ("**P**ull **C**ords **A**part"). * **Most common cause of unilateral RLN palsy:** Thyroid surgery or Bronchogenic carcinoma (Left side).

Question 96: Which of the following procedures is NOT done in bilateral abductor palsy of vocal cords?

A. Teflon paste injection (Correct Answer)
B. Cordectomy
C. Nerve muscle implant
D. Arytenoidectomy

Explanation: **Explanation:** In **Bilateral Abductor Palsy**, the vocal cords are paralyzed in the midline or paramedian position. This results in a compromised airway (stridor) but a relatively preserved voice. The primary goal of management is to **widen the glottic chink** to improve breathing. **Why Teflon Paste Injection is the Correct Answer:** Teflon paste injection is a **medialization procedure**. It is used to add bulk to a vocal cord that is paralyzed in the lateral position (Unilateral Vocal Cord Palsy) to improve glottic closure and voice quality. In bilateral abductor palsy, the cords are already at the midline; injecting Teflon would further narrow the airway, potentially causing total obstruction. Therefore, it is contraindicated. **Analysis of Other Options:** * **Cordectomy:** Involves the surgical removal of a portion of the vocal cord (usually the posterior part) to create a larger airway space. * **Arytenoidectomy:** Removal of the arytenoid cartilage (e.g., Woodman’s procedure) to widen the posterior glottis. This is a classic surgical treatment for bilateral abductor palsy. * **Nerve Muscle Implant:** A reinnervation technique (e.g., using the omohyoid muscle and ansa cervicalis) aimed at restoring the function of the posterior cricoarytenoid muscle (the only abductor). **Clinical Pearls for NEET-PG:** * **Most common cause** of bilateral abductor palsy: Thyroid surgery (injury to bilateral Recurrent Laryngeal Nerves). * **Treatment Priority:** Airway first (Tracheostomy if acute), followed by permanent widening procedures (Lateralization). * **Trade-off:** Any procedure that improves the airway in these patients (by lateralizing the cords) will inevitably worsen the quality of the voice.

Question 97: Which one of the following conditions is considered to be definitely precancerous in the larynx?

A. Vocal nodules
B. Angioma of vocal cords
C. Leukoplakia (Correct Answer)
D. None of the above

Explanation: **Explanation:** **Leukoplakia** is the correct answer because it is a clinical term for a white patch on the vocal cords that cannot be characterized clinically or pathologically as any other disease. Histologically, it represents a spectrum ranging from simple hyperplasia and hyperkeratosis to **dysplasia** (mild, moderate, or severe) and carcinoma-in-situ. Because of its potential to progress into invasive squamous cell carcinoma, it is classified as a **premalignant/precancerous lesion**. Chronic irritation from smoking and alcohol are the primary risk factors. **Why other options are incorrect:** * **Vocal Nodules (Singer’s Nodules):** These are benign, inflammatory reactive lesions caused by vocal abuse. They typically occur at the junction of the anterior 1/3 and posterior 2/3 of the vocal cords and have no malignant potential. * **Angioma of Vocal Cords:** These are benign vascular tumors (hemangiomas). While they may cause hoarseness or airway obstruction, they do not undergo malignant transformation. **High-Yield Clinical Pearls for NEET-PG:** * **Pachydermia Laryngis:** A form of chronic hypertrophic laryngitis involving the interarytenoid area; unlike leukoplakia, it is generally **not** considered precancerous. * **Adult-onset Papillomatosis:** Caused by HPV 6 and 11; it has a higher risk of malignant transformation compared to the juvenile variety. * **Management of Leukoplakia:** The gold standard is **microlaryngoscopic (MLS) excision** and mandatory biopsy to rule out invasive malignancy. * **Keratosis with Dysplasia:** The presence of cellular atypia (dysplasia) is the single most important histological predictor of malignant progression.

Question 98: What is the most common site of amyloidosis in the respiratory tract?

A. Lungs
B. Larynx (Correct Answer)
C. Nose
D. Pharynx

Explanation: **Explanation:** **Amyloidosis of the Respiratory Tract** Amyloidosis refers to the extracellular deposition of insoluble fibrillar proteins. In the respiratory tract, it can occur as a systemic manifestation or, more commonly, as a localized process. 1. **Why Larynx is the Correct Answer:** The **larynx** is the most common site for localized amyloidosis in the entire respiratory tract. Within the larynx, the **false vocal cords (ventricular bands)** are the most frequently involved site, followed by the true vocal cords and the subglottis. It typically presents as a slow-growing, non-ulcerated submucosal mass or "fullness," leading to symptoms like progressive hoarseness or stridor. 2. **Analysis of Incorrect Options:** * **Lungs (Option A):** While amyloid can deposit in the lung parenchyma (nodular or diffuse) or tracheobronchial tree, these involvements are statistically less frequent than laryngeal involvement. * **Nose (Option C):** Nasal amyloidosis is rare and usually presents with epistaxis or obstruction, but it is far less common than laryngeal cases. * **Pharynx (Option D):** Involvement of the pharynx or nasopharynx is uncommon and usually occurs as part of a more extensive upper aerodigestive tract involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Type of Amyloid:** Localized laryngeal amyloidosis is usually of the **AL (Light chain)** type. * **Diagnosis:** The gold standard is a biopsy showing **Apple-green birefringence** under polarized light when stained with **Congo Red**. * **Treatment:** The treatment of choice is **CO2 Laser excision** or surgical debulking. It has a high recurrence rate, necessitating long-term follow-up. * **Systemic Workup:** Even if localized, patients must be screened to rule out systemic amyloidosis or multiple myeloma.

Question 99: Which of the following conditions is classified by Cotton's grading system?

A. Laryngeal carcinoma
B. Subglottic stenosis (Correct Answer)
C. Superior laryngeal nerve palsy
D. Vocal cord misuse

Explanation: **Explanation:** **Subglottic stenosis (Option B)** is the correct answer because the **Myer-Cotton Grading System** is the gold standard for clinically classifying the severity of circumferential subglottic stenosis. This system is based on the percentage of luminal cross-sectional area reduction, measured using age-appropriate rigid bronchoscopes: * **Grade I:** < 50% obstruction. * **Grade II:** 51–70% obstruction. * **Grade III:** 71–99% obstruction (identifiable lumen present). * **Grade IV:** Complete obstruction (no detectable lumen). **Analysis of Incorrect Options:** * **Laryngeal Carcinoma (Option A):** Classified using the **TNM staging system** (AJCC), which focuses on tumor extent, nodal involvement, and metastasis, rather than luminal diameter. * **Superior Laryngeal Nerve Palsy (Option C):** Diagnosed via laryngeal electromyography (LEMG) and clinical signs like the "rotation of the posterior commissure" or loss of pitch; it does not use a grading system for stenosis. * **Vocal Cord Misuse (Option D):** These are functional voice disorders (e.g., Muscle Tension Dysphonia) typically assessed via stroboscopy and perceptual scales like the **GRBAS scale**, not the Cotton system. **High-Yield Clinical Pearls for NEET-PG:** * **McCall’s Classification:** Another system for subglottic stenosis based on the length/vertical extent of the lesion. * **Stridor:** Subglottic stenosis typically presents with **biphasic stridor**. * **Common Cause:** Prolonged endotracheal intubation is the most common acquired cause of subglottic stenosis in children and adults.

Question 100: Which of the following are characteristic features of supraglottic carcinoma?

A. Hot potato voice (Correct Answer)
B. Aspiration
C. Smoking is a common risk factor
D. Lymph node metastasis is uncommon

Explanation: **Explanation:** Supraglottic carcinoma involves structures above the vocal cords, including the epiglottis, aryepiglottic folds, and false cords. **Why Option A is correct:** The "Hot Potato Voice" (muffled speech) is a characteristic feature of supraglottic lesions. Large tumors in this region act as a physical mass that alters the resonance of the oropharynx and hypopharynx, similar to the speech pattern seen in peritonsillar abscess or epiglottitis. Unlike glottic cancer, which causes early hoarseness, supraglottic cancer presents with muffled speech because the vocal cords themselves remain mobile in the early stages. **Analysis of Incorrect Options:** * **B. Aspiration:** While advanced tumors can cause dysphagia, aspiration is typically a *late* feature or a complication of surgical resection (supraglottic laryngectomy) rather than a primary diagnostic characteristic. * **C. Smoking is a common risk factor:** While smoking is a risk factor for all laryngeal cancers, it is most strongly associated with **glottic** (vocal cord) carcinoma. Supraglottic cancer has a relatively higher correlation with heavy alcohol consumption compared to glottic types. * **D. Lymph node metastasis is uncommon:** This is incorrect. The supraglottis has a rich lymphatic network. Consequently, **lymph node metastasis is very common** (up to 40-50% at presentation) and often bilateral. In contrast, glottic cancer has a poor lymphatic supply and rarely metastasizes early. **Clinical Pearls for NEET-PG:** * **Glottic Cancer:** Most common type; presents early with hoarseness; best prognosis. * **Supraglottic Cancer:** Presents late; "Hot potato voice" and throat pain; high rate of nodal metastasis. * **Subglottic Cancer:** Rarest; often presents with stridor or airway obstruction.

Practice by Chapter

Acute Laryngitis

Practice Questions

Chronic Laryngitis

Practice Questions

Vocal Cord Nodules and Polyps

Practice Questions

Reinke's Edema

Practice Questions

Laryngeal Papillomatosis

Practice Questions

Vocal Cord Paralysis

Practice Questions

Laryngeal Trauma

Practice Questions

Laryngeal Stenosis

Practice Questions

Laryngeal Cancer

Practice Questions

Laryngomalacia

Practice Questions

Epiglottitis

Practice Questions

Voice Disorders

Practice Questions

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