Diseases of the Larynx Practice Questions

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

Carcinoma. **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.

Q: 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?

Subtotal laryngectomy. **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.

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

Teflon paste injection. **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.

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

Leukoplakia. **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.

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

Larynx. **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.

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

Subglottic stenosis. **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.

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.

Question 1

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

Accepted Answer

Carcinoma

Answer

Tuberculosis

Answer

Tetanus

Answer

Diphtheria

Question 2

What is the treatment of choice for recurrent respiratory papillomatosis?

Accepted Answer

Laser ablation

Answer

Diathermy excision

Answer

Excision with microdebrider

Answer

Wait for spontaneous resolution

Question 3

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

Accepted Answer

A lesion of the laryngeal surface of the epiglottis below the hyoid bone with evidence of preepiglottic space invasion on computed tomography

Answer

A T2 lesion of the right aryepiglottic fold, a right false vocal cord, and impaired mobility of the true vocal cord

Answer

A lesion of the epiglottis, vallecula, and 1-cm, unilateral extension to the tongue base

Answer

An invasive lesion of the false vocal cord that is found to extend significantly into the ventricle at the time of surgical endoscopy

Question 4

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?

Accepted Answer

Subtotal laryngectomy

Answer

Stripping of the vocal cord

Answer

Radiotherapy

Answer

Laser cordectomy

Question 5

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

Accepted Answer

Abducted

Answer

Cadaveric

Answer

Adducted

Answer

Paramedian

Question 6

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

Accepted Answer

Teflon paste injection

Answer

Cordectomy

Answer

Nerve muscle implant

Answer

Arytenoidectomy

Question 7

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

Accepted Answer

Leukoplakia

Answer

Vocal nodules

Answer

Angioma of vocal cords

Answer

None of the above

Question 8

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

Accepted Answer

Larynx

Answer

Lungs

Answer

Nose

Answer

Pharynx

Question 9

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

Accepted Answer

Subglottic stenosis

Answer

Laryngeal carcinoma

Answer

Superior laryngeal nerve palsy

Answer

Vocal cord misuse

Question 10

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

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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