Diseases of the Larynx Practice Questions

Q: What is the most common cause of stridor in children?

Laryngomalacia. **Explanation:** **Laryngomalacia** is the most common cause of congenital stridor in infants and the most common congenital anomaly of the larynx. It is characterized by an inward collapse of the supraglottic structures (epiglottis, aryepiglottic folds) during inspiration, leading to a characteristic high-pitched **inspiratory stridor**. The symptoms typically appear within the first two weeks of life, worsen with crying or feeding, and usually resolve spontaneously by 18–24 months as the laryngeal cartilage matures. **Analysis of Incorrect Options:** * **B. Congenital laryngeal paralysis:** This is the second most common cause of congenital stridor. It can be unilateral (often associated with birth trauma or cardiac anomalies) or bilateral (often associated with CNS issues like Arnold-Chiari malformation). * **C. Foreign body in larynx:** While a common cause of *acute* respiratory distress in toddlers, it is not the most common cause overall and typically presents with a sudden onset of choking and cough. * **D. Congenital laryngeal tumors:** These (such as subglottic hemangiomas) are rare. They typically present with progressive stridor and are not as prevalent as laryngomalacia. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Flexible fiberoptic laryngoscopy is the gold standard (shows "Omega-shaped" epiglottis). * **Positioning:** Stridor in laryngomalacia typically **improves in the prone position** and worsens in the supine position. * **Management:** Most cases are managed conservatively. Surgical intervention (**Supraglottoplasty**) is reserved for severe cases with failure to thrive or cor pulmonale.

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

Glottic carcinoma. **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.

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

Trauma. **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.

Q: Which procedure should precede microlaryngoscopy?

Laryngoendoscopy. **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.

Q: Turban epiglottitis is a clinical finding in which of the following conditions?

Tubercular laryngitis. ### Explanation **Correct Option: A. Tubercular Laryngitis** Turban epiglottitis is a classic clinical sign of **secondary laryngeal tuberculosis**. In this condition, the epiglottis becomes markedly swollen and edematous due to infiltration by tuberculous granulomas and lymphatic obstruction. This uniform, pale swelling gives the epiglottis a rounded appearance resembling a **turban**. It is typically associated with active pulmonary tuberculosis, where infected sputum causes "surface infection" of the laryngeal mucosa. **Analysis of Incorrect Options:** * **B. Tubercular pharyngitis:** While TB can affect the pharynx, it usually presents as painful ulcerations (often on the tonsils or posterior wall) rather than the specific "turban" swelling of the epiglottis. * **C. Polypoid degeneration of vocal cord:** Also known as **Reinke’s edema**, this involves bilateral, diffuse swelling of the vocal folds (Reinke’s space), typically due to smoking or vocal abuse. It does not involve the epiglottis. * **D. Subglottic hemangioma:** This is a vascular malformation found below the vocal cords, presenting as inspiratory or biphasic stridor in infants. It does not produce epiglottic changes. **Clinical Pearls for NEET-PG:** * **Most common site in Laryngeal TB:** Posterior commissure (interarytenoid area). * **Classic Appearance:** "Mouse-nibbled" appearance of the vocal cords (due to ulceration). * **Symptoms:** Severe pain (odynophagia) referred to the ear via the vagus nerve (Arnold’s nerve) is a hallmark. * **Mamillated space:** The interarytenoid area often shows a "mamillated" or granular appearance. * **Treatment:** Standard Anti-Tubercular Therapy (ATT).

Q: The best way to diagnose laryngomalacia is:

Flexible fibreoptic laryngoscopy. ### Explanation **Laryngomalacia** is the most common congenital anomaly of the larynx and the leading cause of congenital stridor. It is characterized by "floppy" supraglottic structures that collapse inward during inspiration. **Why Option D is Correct:** The gold standard for diagnosis is **Flexible Fibreoptic Laryngoscopy (FFL)** performed while the patient is **awake and breathing spontaneously**. This allows the clinician to observe the dynamic collapse of the supraglottic tissues (such as omega-shaped epiglottis or shortened aryepiglottic folds) in real-time during the respiratory cycle. **Why Other Options are Incorrect:** * **Option A:** While symptoms (inspiratory stridor worsening when supine or crying) are suggestive, they cannot definitively differentiate laryngomalacia from other causes of stridor like vocal cord palsy or subglottic stenosis. * **Option B:** Soft tissue X-rays are useful for detecting radio-opaque foreign bodies or "steeple signs" in croup, but they cannot capture the dynamic soft tissue collapse characteristic of laryngomalacia. * **Option C:** Direct laryngoscopy under General Anaesthesia (GA) often utilizes muscle relaxants or positive pressure ventilation, which can mask the natural dynamic collapse of the airway, leading to a false-negative result. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** High-pitched inspiratory stridor that appears at 2–4 weeks of age, worsens in the supine position, and improves when prone. * **Key Findings on FFL:** 1. **Omega-shaped (Ω) epiglottis** (most common). 2. Shortened aryepiglottic folds. 3. Redundant/bulky arytenoid mucosa. * **Management:** Most cases (90%) are self-limiting and resolve by 18–24 months. **Supraglottoplasty** is the surgical treatment of choice for severe cases (e.g., failure to thrive, cor pulmonale, or severe apnea).

Q: What is the treatment of choice for T1N0M0 glottic carcinoma?

External beam radiotherapy. ### Explanation **Concept Overview:** T1N0M0 glottic carcinoma refers to a tumor limited to the vocal cords (with normal mobility) and no nodal or distant metastasis. The primary goal of treatment in early glottic cancer is **cure with preservation of voice quality.** **Why Option D is Correct:** **External Beam Radiotherapy (EBRT)** is considered the treatment of choice because it offers excellent local control rates (85-95%) while maintaining a superior post-treatment voice quality compared to traditional surgery. Since the vocal cords are not physically altered or excised, the mucosal wave is preserved, leading to a near-normal voice. **Analysis of Incorrect Options:** * **A. Surgery:** While **Transoral Laser Microsurgery (TLM)** is an equally effective alternative for T1 lesions, "Surgery" as a general term often implies cordectomy. Surgery is usually reserved for patients who cannot commit to daily radiation schedules or for recurrences. In most standard protocols, EBRT is preferred for its functional outcome. * **B. Brachytherapy:** This involves placing radioactive sources directly into the tissue. It is rarely used for glottic cancer due to the risk of cartilage necrosis and the technical difficulty of placement in the larynx. * **C. Chemotherapy:** Early-stage (T1/T2) glottic cancer is highly radiosensitive. Chemotherapy is reserved for advanced stages (T3/T4) as part of concurrent chemoradiation for organ preservation. **NEET-PG High-Yield Pearls:** * **Most common site** of laryngeal cancer: Glottis. * **Best prognosis** in laryngeal cancer: Glottic (due to sparse lymphatic drainage, leading to late metastasis). * **Earliest symptom** of glottic cancer: Hoarseness of voice. * **Treatment for T1/T2:** Radiotherapy or Laser Surgery (TLM). * **Treatment for T3/T4:** Concurrent Chemoradiotherapy or Total Laryngectomy.

Question 1

Respiratory distress is seen in which condition?

Accepted Answer

Bilateral abductor palsy

Answer

Unilateral abductor palsy

Answer

Recurrent laryngeal nerve (RLN) palsy, unilateral

Answer

None of the above

Question 2

A 2-week-old neonate presents with a history of stridor that improves when the baby assumes the prone position. What is the recommended management?

Accepted Answer

Observation and reassurance (wait and watch)

Answer

Oral calcium

Answer

Nebulization

Answer

Antibiotic therapy

Question 3

Which of the following is true about juvenile respiratory papillomatosis?

Accepted Answer

Microlaryngoscopic surgery is the treatment of choice

Answer

Affects children commonly

Answer

Lower respiratory tract can be involved

Answer

May resolve spontaneously

Question 4

What is the most common cause of stridor in children?

Accepted Answer

Laryngomalacia

Answer

Congenital laryngeal paralysis

Answer

Foreign body in larynx

Answer

Congenital laryngeal tumors

Question 5

Hoarseness of voice occurs early in which of the following conditions?

Accepted Answer

Glottic carcinoma

Answer

Subglottic carcinoma

Answer

Supraglottic carcinoma

Answer

None of the above

Question 6

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

Accepted Answer

Trauma

Answer

Carcinoma of the thyroid

Answer

Carcinoma of the esophagus

Answer

Idiopathic

Question 7

Which procedure should precede microlaryngoscopy?

Accepted Answer

Laryngoendoscopy

Answer

Pharyngoscopy

Answer

Esophagoscopy

Answer

Rhinoscopy

Question 8

Turban epiglottitis is a clinical finding in which of the following conditions?

Accepted Answer

Tubercular laryngitis

Answer

Tubercular pharyngitis

Answer

Polypoid degeneration of vocal cord

Answer

Subglottic hemangioma

Question 9

The best way to diagnose laryngomalacia is:

Accepted Answer

Flexible fibreoptic laryngoscopy

Answer

Symptoms and signs of disease only

Answer

Soft tissue lateral view neck

Answer

Direct laryngoscopy under general anaesthesia

Question 10

What is the treatment of choice for T1N0M0 glottic carcinoma?

Accepted Answer

External beam radiotherapy

Answer

Surgery

Answer

Brachytherapy

Answer

Chemotherapy

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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