Diseases of the Larynx Practice Questions

Q: Which of the following statements about external laryngocele is FALSE?

Herniates through the cricothyroid membrane.. ### Explanation A **laryngocele** is an abnormal cystic dilatation of the saccule of the laryngeal ventricle, filled with air. Understanding its anatomy is key to identifying the correct answer. **Why Option D is the Correct (False) Statement:** An external laryngocele extends superiorly and exits the larynx by piercing the **thyrohyoid membrane**, specifically at the point where the superior laryngeal vessels and internal laryngeal nerve enter. It does **not** herniate through the cricothyroid membrane. The cricothyroid membrane is located lower in the larynx and is not the anatomical route for saccular herniation. **Analysis of Other Options:** * **Option A:** Because the laryngocele is air-filled and communicates with the airway, any increase in intralaryngeal pressure (like the **Valsalva maneuver**) causes the neck swelling to enlarge and become more prominent. This is a classic clinical sign (Bryce’s sign). * **Option B:** All laryngoceles originate from the **saccule of the laryngeal ventricle**. In an external laryngocele, the neck swelling maintains this communication via a stalk. * **Option C:** **CT scan** is the gold standard for diagnosis. It shows a well-defined, air-filled (or fluid-filled if infected) sac. It helps differentiate it from other neck masses like branchial cysts. **High-Yield Clinical Pearls for NEET-PG:** * **Types:** Internal (confined to endolarynx), External (pierces thyrohyoid membrane), and Combined (most common). * **Risk Factors:** Activities that increase intralaryngeal pressure (e.g., trumpet players, glass blowers) or obstructing laryngeal tumors (always perform direct laryngoscopy to rule out **squamous cell carcinoma** at the neck of the saccule). * **Laryngopyocele:** When a laryngocele becomes infected and filled with pus. * **Bryce’s Sign:** Gurgling sound heard on compression of the neck swelling.

Q: All of the following spaces are seen in relation to the larynx except?

Space of Gillette. ### Explanation The correct answer is **D. Space of Gillette**, as it is a retropharyngeal space, not a laryngeal space. #### 1. Why "Space of Gillette" is the correct answer: The **Space of Gillette** (also known as the **Retropharyngeal Space**) is a potential space located behind the pharynx, bounded anteriorly by the buccopharyngeal fascia and posteriorly by the prevertebral fascia. It contains the Nodes of Rouviere. Clinically, it is significant as a site for retropharyngeal abscesses, particularly in children, but it is anatomically distinct from the internal structure of the larynx. #### 2. Analysis of Incorrect Options (Laryngeal Spaces): * **Space of Boyer (Pre-epiglottic Space):** This is a wedge-shaped space located anterior to the epiglottis. It is bounded by the thyroid cartilage and thyrohyoid membrane anteriorly, and the epiglottis posteriorly. It is a common route for the spread of supraglottic tumors. * **Space of Tucker (Paraglottic Space):** This is a potential space lateral to the endolarynx. It is bounded by the thyroid cartilage laterally and the conus elasticus/quadrangular membrane medially. It allows for the transglottic spread of laryngeal cancer. * **Reinke’s Space:** This is a potential space in the lamina propria of the vocal folds, located between the vocal ligament and the overlying epithelium. Accumulation of fluid here leads to **Reinke’s Edema**, often seen in chronic smokers. #### 3. High-Yield Clinical Pearls for NEET-PG: * **Transglottic Spread:** Laryngeal cancers often cross the ventricle to involve both supraglottis and glottis by invading the **Paraglottic space (Tucker's)**. * **Hyo-epiglottic Ligament:** This forms the "roof" of the pre-epiglottic space. * **Reinke’s Edema:** Characterized by a "low-pitched, gravelly voice" and is typically treated with smoking cessation and microlaryngeal surgery (decortication).

Q: An infant after birth is noticed to have stridor and a hoarse cry. All of the following diagnoses are possible except:

Laryngomalacia. **Explanation:** The key to solving this question lies in differentiating between the clinical presentations of various causes of congenital stridor. **Why Laryngomalacia is the correct answer:** Laryngomalacia is the most common cause of congenital stridor. However, its hallmark feature is a **normal, clear cry**. The pathology involves supraglottic collapse (floppy aryepiglottic folds or omega-shaped epiglottis) during inspiration, which does not affect the vocal cords themselves. Therefore, while it causes inspiratory stridor that worsens with crying or supine positioning, the voice/cry remains unaffected. **Analysis of Incorrect Options:** * **Laryngeal Web:** These are most commonly glottic (75%). Because they involve the vocal folds, they characteristically present with both stridor and a **hoarse cry** or even aphonia from birth. * **Laryngeal Paralysis:** Congenital vocal cord paralysis (often bilateral) presents immediately at birth with significant respiratory distress and a **weak or hoarse cry** due to the inability of the cords to adduct/abduct properly. * **Congenital Laryngeal Cyst:** Large saccular cysts can displace the endolarynx and interfere with vocal cord vibration or glottic patency, leading to both stridor and **muffled or hoarse phonation**. **NEET-PG Clinical Pearls:** * **Laryngomalacia:** Most common cause of stridor in neonates; stridor is **inspiratory** and improves in the **prone** position. * **Hoarseness in an infant:** Always points toward a pathology involving the **glottis** (vocal cords). * **Laryngeal Web:** Associated with **DiGeorge Syndrome** (22q11 deletion). * **Subglottic Stenosis:** Most common cause of congenital stridor requiring tracheostomy; cry is usually normal, but stridor is **biphasic**.

Q: Which of the following are characteristic features of supraglottic carcinoma?

Hot potato voice. **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.

Q: Type I thyroplasty is indicated for which of the following conditions?

Vocal cord medialization. **Explanation:** Thyroplasty, also known as **Isshiki’s Phonosurgery**, refers to a group of surgical procedures performed on the thyroid cartilage to alter the position or tension of the vocal cords to improve voice quality. **1. Why Vocal Cord Medialization is Correct:** **Type I Thyroplasty** is specifically designed for **medialization** of the vocal cord. It is indicated in cases of unilateral vocal cord paralysis (e.g., recurrent laryngeal nerve injury) or vocal cord atrophy where a "glottic gap" exists. A window is created in the thyroid cartilage, and a silastic or Gore-Tex implant is inserted to push the paralyzed cord toward the midline, allowing the healthy cord to make contact (adduction) for better phonation and cough reflex. **2. Analysis of Incorrect Options:** * **Type II (Lateralization):** Indicated for **vocal cord lateralization**. It is used in conditions like adductor spasmodic dysphonia to move the cords apart and reduce the "strangled" voice quality. * **Type III (Shortening/Relaxation):** Indicated for **shortening** or relaxing the vocal cords. This lowers the pitch of the voice (used in Mutational Falsetto/Puberphonia if speech therapy fails). * **Type IV (Lengthening/Tension):** Indicated for **lengthening** or increasing the tension of the vocal cords. This raises the pitch of the voice (used in Androphonia or for gender reassignment). **Clinical Pearls for NEET-PG:** * **Most common type:** Type I (Medialization) is the most frequently performed thyroplasty. * **Anesthesia:** These procedures are ideally done under **local anesthesia** so the surgeon can monitor the patient's voice quality in real-time to adjust the implant. * **Alternative for Medialization:** Injection laryngoplasty (using Teflon, Gelfoam, or Fat) is another method for medialization but is less reversible than Type I Thyroplasty.

Q: All of the following statements about Recurrent Laryngeal Papillomatosis are true, EXCEPT:

HPV6 is more virulent than HPV11. **Explanation:** Recurrent Respiratory Papillomatosis (RRP) is the most common benign neoplasm of the larynx in children. The correct answer is **C** because it is a false statement; in clinical practice, **HPV-11 is considered more virulent** than HPV-6. HPV-11 is associated with a more aggressive clinical course, higher rates of airway obstruction, and a greater need for frequent surgical interventions. **Analysis of Options:** * **Option A & B:** RRP is caused by the **Human Papilloma Virus (HPV)**. Specifically, **types 6 and 11** are responsible for over 90% of cases. These are "low-risk" types (non-oncogenic), though rare malignant transformation to squamous cell carcinoma can occur. * **Option D:** The primary mode of transmission in the juvenile form is **vertical transmission** during birth. The neonate acquires the virus while passing through an infected birth canal (maternal genital warts/condyloma acuminatum). **Clinical Pearls for NEET-PG:** * **Triad of symptoms:** Hoarseness of voice (most common early sign), stridor (initially inspiratory), and chronic cough. * **Diagnosis:** Direct laryngoscopy shows characteristic "cauliflower-like" exophytic lesions. * **Management:** The gold standard is **Surgical Debridement** (CO2 laser or microdebrider) to maintain airway patency. It is not curative, as the virus remains latent in the basal layer of the mucosa. * **Adjuvant Therapy:** Cidofovir (antiviral) is sometimes used for aggressive cases. * **Prevention:** The quadrivalent and nonavalent HPV vaccines are highly effective in reducing the incidence of maternal transmission.

Q: The voice is not affected in which of the following conditions?

Unilateral abductor palsy. **Explanation:** The quality of voice depends primarily on the ability of the vocal cords to meet in the midline (adduction) and vibrate effectively. **Why Unilateral Abductor Palsy is the correct answer:** In unilateral abductor palsy (paralysis of the Posterior Cricoarytenoid muscle), the affected vocal cord remains in the **median or paramedian position**. Because the cord is already at or near the midline, the healthy vocal cord can easily make contact with it during phonation. As a result, the glottic gap is closed, and the **voice remains normal or near-normal**. The primary symptom in these patients is often mild exertional dyspnea rather than dysphonia. **Analysis of Incorrect Options:** * **Unilateral Adductor Palsy:** The affected cord remains in the abducted (lateral) position. The healthy cord cannot cross the midline to meet it, resulting in a large glottic gap, leading to a **breathy, weak voice (hoarseness)**. * **Bilateral Superior Laryngeal Palsy:** This involves paralysis of the cricothyroid muscles, which are responsible for tensing the cords. This leads to a loss of longitudinal tension, resulting in a **weak, low-pitched voice** and an inability to sing high notes. * **Total Adductor Palsy:** Similar to unilateral adductor palsy but more severe; the inability to adduct the cords leads to significant air leak and a **whispering voice or aphonia**. **Clinical Pearls for NEET-PG:** * **Posterior Cricoarytenoid (PCA):** The only abductor of the vocal cords ("**P**ull **C**ords **A**part"). * **Semon’s Law:** In progressive lesions of the recurrent laryngeal nerve, abductor fibers are more susceptible and paralyzed first; the cord moves to the midline. * **Position of Cords:** In **bilateral abductor palsy**, the voice is good, but the airway is compromised (stridor), often requiring a tracheostomy. In **bilateral adductor palsy**, the airway is excellent, but the patient is aphonic.

Q: The most common and earliest manifestation of carcinoma of the glottis is:

Hoarseness. **Explanation:** **Why Hoarseness is the Correct Answer:** The glottis is the most common site for laryngeal carcinoma. Because the vocal cords are involved early in the disease process, even a tiny lesion (as small as 1-2 mm) interferes with the precise vibratory pattern and edge-to-edge approximation of the cords. This results in **hoarseness of voice**, which is both the **earliest** and the **most common** presenting symptom. Due to this early warning sign, glottic cancers are often diagnosed at an early stage (T1/T2). **Analysis of Incorrect Options:** * **B. Haemoptysis:** This is a late feature occurring due to the ulceration and necrosis of the tumor mass. It is rarely the presenting complaint in glottic lesions. * **C. Cervical Lymph Nodes:** The glottic region has a very **sparse lymphatic drainage**. Consequently, nodal metastasis is extremely rare in early glottic cancer (unlike supraglottic cancer, which presents early with neck nodes). * **D. Stridor:** This is a sign of significant airway obstruction. It occurs in advanced stages when the tumor has grown large enough to narrow the rima glottidis. **Clinical Pearls for NEET-PG:** * **Best Prognosis:** Glottic cancer has the best prognosis among laryngeal cancers because it presents early (hoarseness) and has a low rate of lymphatic spread. * **Supraglottic Cancer:** Often presents late with "hot potato voice," throat pain, or a neck mass (cervical lymphadenopathy). * **Definition of Chronic Hoarseness:** Any patient with hoarseness persisting for more than **3 weeks** must undergo indirect laryngoscopy (IDL) or fiberoptic laryngoscopy to rule out malignancy.

Q: Vocal cord palsy is not caused by which of the following?

Vertebral secondaries. **Explanation:** The movement of the vocal cords is controlled by the **Recurrent Laryngeal Nerve (RLN)**, a branch of the Vagus nerve (CN X). The RLN has a long, circuitous course, especially on the left side, making it vulnerable to compression by various intrathoracic and cervical pathologies. **Why Vertebral Secondaries is the correct answer:** Vertebral secondaries (metastasis to the spinal column) typically involve the bony structures of the neck or back. The RLN runs in the **tracheoesophageal groove** and does not come into direct anatomical contact with the vertebral bodies. Therefore, isolated vertebral secondaries are unlikely to cause vocal cord palsy unless there is massive pre-vertebral extension involving the Vagus or RLN. **Analysis of Incorrect Options:** * **Left Atrial Enlargement:** This causes **Ortner’s Syndrome** (Cardiovocal syndrome). The enlarged left atrium pushes the left pulmonary artery upwards, compressing the left RLN against the aortic arch. * **Bronchogenic Carcinoma:** This is the most common malignant cause of left RLN palsy. Tumors in the apex of the lung (Pancoast tumor) or hilar lymphadenopathy can directly invade or compress the nerve. * **Secondaries in Mediastinum:** The RLN (particularly the left) loops around the arch of aorta in the superior mediastinum. Metastatic lymphadenopathy (e.g., from lung or esophageal cancer) in this region frequently results in nerve compression. **High-Yield Clinical Pearls for NEET-PG:** 1. **Left vs. Right:** Left vocal cord palsy is more common than right because the left RLN is longer and loops around the **Aortic Arch**, while the right RLN loops around the **Subclavian Artery**. 2. **Ortner’s Syndrome:** Classically associated with Mitral Stenosis leading to left atrial enlargement. 3. **Semon’s Law:** In progressive lesions, abductor fibers are injured first; hence the cord initially lies in the midline.

Question 1

Which of the following statements about external laryngocele is FALSE?

Accepted Answer

Herniates through the cricothyroid membrane.

Answer

Produces a swelling in the neck on Valsalva maneuver.

Answer

Communicates with the laryngeal ventricle.

Answer

Can be identified on CT scan.

Question 2

All of the following spaces are seen in relation to the larynx except?

Accepted Answer

Space of Gillette

Answer

Space of Boyer

Answer

Space of Trucker

Answer

Reinke's space

Question 3

An infant after birth is noticed to have stridor and a hoarse cry. All of the following diagnoses are possible except:

Accepted Answer

Laryngomalacia

Answer

Laryngeal web

Answer

Laryngeal paralysis

Answer

Congenital laryngeal cyst

Question 4

Which of the following are characteristic features of supraglottic carcinoma?

Accepted Answer

Hot potato voice

Answer

Aspiration

Answer

Smoking is a common risk factor

Answer

Lymph node metastasis is uncommon

Question 5

Type I thyroplasty is indicated for which of the following conditions?

Accepted Answer

Vocal cord medialization

Answer

Vocal cord lateralization

Answer

Vocal cord shortening

Answer

Vocal cord lengthening

Question 6

A patient presented with hoarseness of voice and was found to be having pachydermia laryngitis. Which of the following statements is incorrect?

Accepted Answer

It is a hyperkeratotic lesion present predominantly on the vocal cords.

Answer

It is not a premalignant lesion.

Answer

Diagnosis is confirmed by biopsy.

Answer

Microscopy shows acanthosis and hyperkeratosis.

Question 7

All of the following statements about Recurrent Laryngeal Papillomatosis are true, EXCEPT:

Accepted Answer

HPV6 is more virulent than HPV11

Answer

Caused by Human Papilloma Virus (HPV)

Answer

HPV6 and HPV11 are most commonly implicated

Answer

Transmission to neonate occurs through contact with mother during vaginal delivery

Question 8

The voice is not affected in which of the following conditions?

Accepted Answer

Unilateral abductor palsy

Answer

Unilateral adductor palsy

Answer

Bilateral superior laryngeal palsy

Answer

Total adductor palsy

Question 9

The most common and earliest manifestation of carcinoma of the glottis is:

Accepted Answer

Hoarseness

Answer

Haemoptysis

Answer

Cervical lymph nodes

Answer

Stridor

Question 10

Vocal cord palsy is not caused by which of the following?

Accepted Answer

Vertebral secondaries

Answer

Left atrial enlargement

Answer

Bronchogenic carcinoma

Answer

Secondaries in mediastinum

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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