Diseases of the Larynx — MCQs

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 101: Type I thyroplasty is indicated for which of the following conditions?

A. Vocal cord medialization (Correct Answer)
B. Vocal cord lateralization
C. Vocal cord shortening
D. Vocal cord lengthening

Explanation: **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.

Question 102: A patient presented with hoarseness of voice and was found to be having pachydermia laryngitis. Which of the following statements is incorrect?

A. It is a hyperkeratotic lesion present predominantly on the vocal cords. (Correct Answer)
B. It is not a premalignant lesion.
C. Diagnosis is confirmed by biopsy.
D. Microscopy shows acanthosis and hyperkeratosis.

Explanation: **Explanation:** **Pachydermia Laryngitis** is a specific form of chronic hypertrophic laryngitis characterized by localized thickening of the epithelium. **1. Why Option A is the correct answer (Incorrect statement):** Pachydermia laryngitis characteristically involves the **posterior part of the larynx**, specifically the **interarytenoid area** and the posterior third of the vocal cords (vocal processes). It does *not* predominantly involve the membranous vocal cords. The lesion appears as a "heaping up" of epithelium in the interarytenoid space, often with a central depression or ulceration on one side and a corresponding projection on the other. **2. Analysis of other options:** * **Option B:** Unlike other forms of chronic laryngitis (like leukoplakia), Pachydermia is **not considered a premalignant lesion**. It does not show cellular atypia or progress to carcinoma. * **Option C:** While the clinical appearance is suggestive, a **biopsy** is essential to confirm the diagnosis and, more importantly, to rule out malignancy or granulomatous diseases like tuberculosis. * **Option D:** Histologically, the condition is defined by **acanthosis** (thickening of the prickle cell layer) and **hyperkeratosis** (thickening of the stratum corneum). The underlying stroma shows inflammatory cell infiltration. **Clinical Pearls for NEET-PG:** * **Etiology:** Strongly associated with chronic irritation from **alcohol, heavy smoking**, and **Gastroesophageal Reflux Disease (GERD)**. * **Clinical Presentation:** Persistent hoarseness and a "foreign body" sensation in the throat. * **Management:** Treatment is difficult; it involves voice rest, smoking cessation, and aggressive anti-reflux therapy. Surgical excision is reserved for biopsy or if the mass is large enough to cause mechanical issues. * **Key Distinction:** Remember that **Leukoplakia** is premalignant and occurs on the vocal cords, whereas **Pachydermia** is benign and occurs in the interarytenoid region.

Question 103: What does Bernoulli's theorem explain in the context of laryngeal function?

A. Nasal polyp (Correct Answer)
B. Thyroglossal cyst
C. Zenker's diverticulum
D. Laryngomalacia

Explanation: **Explanation:** **Bernoulli’s Theorem** states that in a flowing fluid (or air), an increase in velocity occurs simultaneously with a decrease in pressure. In the context of ENT, this principle is the primary physical explanation for the formation and growth of **Nasal Polyps**. 1. **Why Nasal Polyp is correct:** According to the Bernoulli principle, as air passes through the narrow nasal passages, its velocity increases, creating a negative pressure (suction effect) on the mucosa. In the presence of chronic inflammation or edema, this negative pressure pulls the loosened mucosal lining outward, leading to the formation and progressive enlargement of a polypoid mass. 2. **Why other options are incorrect:** * **Thyroglossal Cyst:** This is a congenital developmental abnormality resulting from the failure of the thyroglossal duct to obliterate. * **Zenker’s Diverticulum:** This is a pulsion diverticulum caused by high intrapharyngeal pressure and incoordination of the cricopharyngeus muscle (Killian’s dehiscence). * **Laryngomalacia:** This is caused by congenital flaccidity of the supraglottic structures (aryepiglottic folds), leading to inspiratory stridor. While airflow dynamics are involved, the primary pathology is structural weakness, not Bernoulli’s principle. **High-Yield Clinical Pearls for NEET-PG:** * **Bernoulli’s Principle in Larynx:** It also explains the **vocal fold vibration** (Myoelastic-Aerodynamic Theory). As air rushes through the glottis, the drop in pressure sucks the vocal cords together. * **Nasal Polyps:** Most commonly arise from the **Ethmoidal sinuses** (middle meatus). * **Samter’s Triad:** Aspirin sensitivity, Asthma, and Nasal Polyposis. * **Vocal Nodules:** Also influenced by Bernoulli's effect, as the constant suction and high-velocity airflow contribute to mucosal trauma at the junction of the anterior 1/3 and posterior 2/3 of the vocal cords.

Question 104: In indirect laryngoscopy, which of the following is not visualized?

A. Base of tongue
B. Pyriform fossa
C. Glottis
D. Subglottis (Correct Answer)

Explanation: **Explanation:** Indirect Laryngoscopy (IDL) is a clinical procedure that uses a laryngeal mirror to visualize the larynx and surrounding structures. The correct answer is **Subglottis** because it is a "blind spot" in this procedure. **1. Why Subglottis is the correct answer:** The subglottis is the region located immediately below the true vocal cords. During IDL, the view is obstructed by the vocal cords themselves. Furthermore, the subglottis is situated deep and at an angle that the reflected light from a laryngeal mirror cannot reach. Visualization of the subglottis usually requires **Direct Laryngoscopy** or a flexible fiberoptic bronchoscope. **2. Why other options are incorrect:** * **Base of tongue:** This is the first structure encountered as the mirror is positioned; it forms the anterior boundary of the vallecula and is easily seen. * **Pyriform fossa:** These are mucosal recesses located on either side of the laryngeal inlet. They are clearly visible during IDL, especially when the patient phonates. * **Glottis:** The glottis (true vocal cords and the space between them) is the primary structure evaluated during IDL to check for mobility and pathology. **NEET-PG High-Yield Pearls:** * **Structures NOT seen on IDL (Blind Spots):** Subglottis, Ventricle of larynx, Anterior commissure, and the Posterior surface of the epiglottis. * **Positioning:** IDL is performed in the **"Sniffing position"** (extension at atlanto-occipital joint and flexion at lower cervical spine). * **Nerve Supply:** The gag reflex during IDL is mediated by the **Glossopharyngeal nerve (CN IX)** as the sensory limb and the **Vagus nerve (CN X)** as the motor limb. * **Image Characteristics:** The image seen in IDL is **inverted (anteroposteriorly)** but not reversed laterally.

Question 105: The most common and earliest manifestation of carcinoma of the glottis is:

A. Hoarseness (Correct Answer)
B. Haemoptysis
C. Cervical lymph nodes
D. Stridor

Explanation: **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.

Question 106: Which of the following is true about juvenile respiratory papillomatosis?

A. Affects children commonly
B. Lower respiratory tract can be involved
C. May resolve spontaneously
D. Microlaryngoscopic surgery is the treatment of choice (Correct Answer)

Explanation: **Explanation:** **Juvenile Onset Recurrent Respiratory Papillomatosis (JORRP)** is the most common benign neoplasm of the larynx in children, primarily caused by **Human Papillomavirus (HPV) types 6 and 11**. 1. **Why Option D is correct:** The primary goal of management is to maintain a patent airway and preserve voice quality. **Microlaryngoscopic surgery (MLS)** using a **CO2 laser** or **Microdebrider** is the treatment of choice. It allows for precise removal of papillomas while minimizing trauma to the underlying vocal ligament, which prevents scarring and synechia formation. 2. **Why other options are incorrect:** * **Option A:** While it "commonly" affects children, in the context of NEET-PG "Multiple Choice" logic, Option D is the definitive clinical management fact. Furthermore, the disease has a bimodal distribution (Juvenile and Adult onset), making surgery the more specific "true" statement regarding management. * **Option B:** The disease primarily involves the larynx (glottis and false cords). While distal spread to the trachea or lungs can occur in aggressive cases (approx. 2-5%), it is a **rare complication** rather than a defining feature. * **Option C:** JORRP is notorious for its **relentless recurrence**. It does not typically resolve spontaneously; instead, it often requires multiple surgical interventions until the patient reaches puberty, where some cases may see remission. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of symptoms:** Hoarseness of voice, stridor, and respiratory distress. * **Transmission:** Vertical transmission from mother to child during childbirth (associated with maternal genital warts). * **Adjuvant Therapy:** Indicated if >4 surgeries/year. Options include **Cidofovir** (intralesional), Interferon-alpha, and Indole-3-carbinol. * **Tracheostomy:** Should be avoided if possible, as it can lead to "seeding" of the virus into the lower respiratory tract.

Question 107: Which of the following statements is true regarding Infraglottic carcinoma of the larynx?

A. It commonly spreads to mediastinal nodes. (Correct Answer)
B. It is the second most common carcinoma of the larynx.
C. It is the most common carcinoma of the larynx.
D. It spreads to submental nodes.

Explanation: ### Explanation **1. Why Option A is Correct:** Infraglottic (subglottic) carcinoma is characterized by its unique lymphatic drainage. The subglottis drains primarily through the **cricothyroid membrane** to the **prelaryngeal (Delphian) nodes** and **paratracheal nodes**. From the paratracheal chain, the malignancy frequently extends inferiorly into the **superior mediastinal lymph nodes**. This deep and often occult lymphatic spread is a hallmark of subglottic tumors, contributing to their poor prognosis and late presentation. **2. Why the Other Options are Incorrect:** * **Options B & C:** Subglottic carcinoma is actually the **least common** site for laryngeal cancer, accounting for only about 1–5% of cases. Glottic carcinoma (vocal cords) is the most common (60–65%), followed by supraglottic carcinoma (30–35%). * **Option D:** Submental nodes (Level Ia) primarily drain the floor of the mouth, tip of the tongue, and lower lip. They are not the primary drainage site for any laryngeal subsite. **3. Clinical Pearls for NEET-PG:** * **Silent Zone:** The subglottis is often called a "clinically silent" area because tumors here do not cause early symptoms like hoarseness. * **Presentation:** The most common presenting symptom is **stridor** or dyspnea, which usually indicates an advanced stage. * **Prognosis:** It has the worst prognosis among the three laryngeal subsites due to the high incidence of early lymphatic spread to paratracheal and mediastinal nodes. * **Staging Tip:** Any tumor limited to the subglottis is T1; involvement of the vocal cords with normal mobility is T2.

Question 108: Hoarseness of voice occurs early in which of the following conditions?

A. Glottic carcinoma (Correct Answer)
B. Subglottic carcinoma
C. Supraglottic carcinoma
D. None of the above

Explanation: **Explanation:** The correct answer is **Glottic carcinoma**. This is a high-yield concept in ENT based on the anatomical and physiological characteristics of the larynx. **1. Why Glottic Carcinoma is the correct answer:** The glottis consists of the true vocal cords. Since the primary function of the vocal cords is phonation, any mucosal irregularity, growth, or mass—even a very small one—immediately disrupts the smooth vibratory pattern and closure of the cords. This results in **hoarseness of voice** as the earliest presenting symptom. Because this symptom appears early, glottic tumors are often diagnosed at an early stage (T1), leading to a better prognosis. **2. Why the other options are incorrect:** * **Supraglottic Carcinoma:** The supraglottis (epiglottis, aryepiglottic folds, false cords) is a "roomy" area. Tumors here remain asymptomatic for a long time. They typically present late with symptoms like throat pain, dysphagia, or a "hot potato voice." Hoarseness only occurs if the tumor spreads downwards to involve the true vocal cords. * **Subglottic Carcinoma:** This is a rare site. Tumors here are often "silent" and usually present with **stridor** or airway obstruction rather than hoarseness, as the growth occurs below the level of the vocal cords. **Clinical Pearls for NEET-PG:** * **Lymphatic Drainage:** The glottis has practically **no lymphatic drainage**; hence, nodal metastasis is extremely rare in early glottic cancer. * **Supraglottis:** Has a rich lymphatic network, leading to a high incidence of bilateral cervical lymph node metastasis. * **Rule of Thumb:** Any patient with hoarseness of voice persisting for more than **3 weeks** must undergo indirect laryngoscopy (IDL) or fiberoptic laryngoscopy to rule out malignancy.

Question 109: What is the most common cause of unilateral left vocal cord palsy?

A. Carcinoma of the thyroid
B. Trauma (Correct Answer)
C. Carcinoma of the esophagus
D. Idiopathic

Explanation: **Explanation:** The most common cause of unilateral vocal cord palsy (specifically on the left side) is **Trauma**, with surgical trauma being the leading subtype. **Why Trauma is the Correct Answer:** The left recurrent laryngeal nerve (RLN) has a longer, more convoluted intrathoracic course compared to the right. It loops under the arch of the aorta before ascending in the tracheoesophageal groove. This extended anatomy makes it highly susceptible to injury during various surgeries, including thyroidectomy, esophagectomy, and especially cardiothoracic procedures (e.g., PDA ligation or lung resections). Statistically, surgical trauma remains the most frequent etiology in modern clinical practice. **Analysis of Incorrect Options:** * **Carcinoma of the thyroid:** While a significant cause of RLN palsy, it is less common than surgical trauma. If a patient presents with palsy *and* a thyroid mass, malignancy is highly suspected, but it is not the most common cause overall. * **Carcinoma of the esophagus:** This can cause palsy due to the nerve's proximity in the tracheoesophageal groove, but it is statistically less frequent than trauma. * **Idiopathic:** Historically, many cases were labeled idiopathic; however, with improved diagnostic imaging, most cases are now attributed to specific traumatic or neoplastic causes. **NEET-PG High-Yield Pearls:** * **Left vs. Right:** Left-sided palsy is more common than right-sided palsy (ratio ~2:1) due to the longer course of the left RLN. * **Ortner’s Syndrome:** Left RLN palsy caused by cardiovascular conditions (e.g., mitral stenosis leading to left atrial enlargement) is a classic exam favorite. * **Position of Cord:** In unilateral RLN palsy, the affected cord usually lies in the **paramedian position** because the cricothyroid muscle (supplied by the Superior Laryngeal Nerve) remains intact and adducts the cord.

Question 110: Which procedure should precede microlaryngoscopy?

A. Pharyngoscopy
B. Esophagoscopy
C. Rhinoscopy
D. Laryngoendoscopy (Correct Answer)

Explanation: **Explanation:** Microlaryngoscopy (MLS) is a specialized procedure performed under general anesthesia using an operating microscope to visualize and operate on the vocal folds. However, before proceeding with the high-magnification view of the larynx, a **Laryngoendoscopy** (specifically, a direct laryngoscopy) must be performed. **Why Laryngoendoscopy is the correct answer:** The primary goal of performing a direct laryngoscopy before the microscope is introduced is to conduct a **comprehensive survey** of the entire laryngeal and perilaryngeal area (including the vallecula, epiglottis, and aryepiglottic folds). This ensures that no synchronous lesions or structural abnormalities are missed that might be outside the narrow field of view provided by the microscope. It also allows the surgeon to assess the ease of exposure and the stability of the larynx before committing to the microscopic phase. **Analysis of Incorrect Options:** * **Pharyngoscopy:** While the pharynx is visualized during the introduction of the laryngoscope, a formal pharyngoscopy is not a mandatory prerequisite for microlaryngoscopy unless a pharyngeal pathology is suspected. * **Esophagoscopy:** This is a separate procedure to visualize the esophagus. While it may be part of a "triple endoscopy" (panendoscopy) for cancer staging, it is not a routine requirement preceding MLS. * **Rhinoscopy:** This involves the examination of the nasal cavity and is unrelated to the surgical exposure required for laryngeal microsurgery. **High-Yield Clinical Pearls for NEET-PG:** * **Positioning:** Microlaryngoscopy is performed in the **Boyce’s position** (Barking Dog position)—neck flexed and head extended. * **Indication:** It is the gold standard for the excision of vocal nodules, polyps, and Reinke’s edema. * **Complication:** The most common minor complication is tongue numbness or dental injury; the most serious is laryngospasm upon extubation.

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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