Diseases of the Larynx Practice Questions

Q: What is the advantage of flexible bronchoscopy?

All of the above. Flexible bronchoscopy is a versatile diagnostic and therapeutic tool in airway management. Unlike rigid bronchoscopy, which requires general anesthesia and specific neck positioning, the flexible fiberoptic scope offers several distinct advantages: **1. Awake Procedures (Option A):** Flexible bronchoscopy can be performed under local anesthesia (topical lidocaine) with or without conscious sedation. This is crucial for evaluating dynamic airway collapse (tracheomalacia) or performing "awake intubations" in patients with anticipated difficult airways. **2. Distal Reach (Option B):** Due to its small diameter and maneuverability (tip deflection), the flexible scope can navigate beyond the lobar bronchi into the **subsegmental bronchi**. This allows for distal biopsies, brushings, and bronchoalveolar lavage (BAL) in the periphery of the lung, which is impossible with a rigid scope. **3. Anatomical Versatility (Option C):** Rigid bronchoscopy requires "line-of-sight" access, necessitating neck extension and wide jaw opening. Flexible bronchoscopy can be performed via the nasal or oral route and is the preferred method for patients with **cervical spine instability, trismus (lockjaw), or micrognathia**. **Clinical Pearls for NEET-PG:** * **Gold Standard for Foreign Body Removal:** Rigid Bronchoscopy (due to better airway control and larger working channel). * **Gold Standard for Hemoptysis (Massive):** Rigid Bronchoscopy (better suctioning capability). * **Preferred for Peripheral Lesions:** Flexible Bronchoscopy. * **Key Contraindication:** Severe hypoxemia or unstable cardiac status (unless it is to secure the airway).

Q: About laryngomalacia, all are true except?

Curled epiglottis, flaccid arytenoids. **Laryngomalacia** is the most common congenital anomaly of the larynx and the leading cause of congenital stridor. It is characterized by an inward collapse of the supraglottic structures during inspiration. ### **Explanation of Options** * **Why Option A is the Correct Answer (The "Except"):** While the epiglottis is indeed curled (Omega-shaped), the primary pathology involves the **aryepiglottic folds**, which are characteristically short and flaccid, causing them to collapse inward. While the arytenoids may appear prominent or "fleshy," the classic description focuses on the shortening and flaccidity of the **aryepiglottic folds** rather than the arytenoids themselves in isolation. Therefore, Option A is the least accurate description compared to the standard clinical definition. * **Option B & C (True Statements):** These describe the classic pathophysiology. The supraglottic larynx is flaccid (C), and the epiglottis is typically elongated and curled upon itself (**Omega-shaped epiglottis**) with shortened, flaccid aryepiglottic folds (B). * **Option D (True Statement):** In approximately 90% of cases, the condition is self-limiting and resolves by 18–24 months of age. Therefore, **conservative management** (observation and reflux control) is the mainstay of treatment. ### **NEET-PG High-Yield Pearls** * **Clinical Presentation:** Inspiratory stridor that increases with crying, feeding, or lying supine; improves when prone. * **Diagnosis:** Flexible fiberoptic laryngoscopy (Gold Standard) showing inward collapse of supraglottic structures. * **Surgical Management:** Indicated only in severe cases (failure to thrive, cor pulmonale, sleep apnea). The procedure of choice is **Supraglottoplasty**. * **Associated Condition:** Gastroesophageal reflux disease (GERD) is frequently present and exacerbates symptoms.

Q: What is the most common cause of acute laryngotracheal bronchitis?

Parainfluenza virus. **Explanation:** **Acute Laryngotracheobronchitis (LTB)**, commonly known as **Croup**, is a viral infection characterized by inflammation and narrowing of the subglottic airway. 1. **Why Parainfluenza virus is correct:** The **Parainfluenza virus (Type 1 and 2)** is the most common causative agent, accounting for nearly 75% of all cases. It typically affects children between 6 months and 3 years of age. The virus causes subglottic edema, leading to the classic clinical triad of **barking cough, inspiratory stridor, and hoarseness.** 2. **Why other options are incorrect:** * **Haemophilus influenzae:** This is the primary cause of **Acute Epiglottitis**, not LTB. Epiglottitis is a medical emergency involving the supraglottic structures and is characterized by the "thumb sign" on X-ray. * **Influenza virus:** While it can cause respiratory infections and occasionally severe croup, it is less common than Parainfluenza. * **Coxsackievirus:** This is typically associated with Herpangina or Hand-Foot-and-Mouth disease, not primary laryngeal infections. **High-Yield Clinical Pearls for NEET-PG:** * **Radiological Sign:** The characteristic X-ray finding in Croup is the **"Steeple Sign"** (subglottic narrowing) on an AP view of the neck. * **Management:** Mild cases are managed with hydration and humidity. Severe cases require **nebulized adrenaline** (to reduce edema) and **corticosteroids** (Dexamethasone). * **Seasonality:** It most commonly occurs in late autumn and winter. * **Differential:** Always differentiate from Epiglottitis (high fever, drooling, sitting in tripod position) and Foreign Body Aspiration.

Q: Which of the following is a symptom of sudden onset bilateral vocal cord palsy?

Dyspnea & Stridor. In bilateral vocal cord palsy (specifically abductor paralysis), both vocal cords assume a **median or paramedian position**. Because the cords cannot move outward (abduct), the glottic airway is severely narrowed. ### Why "Dyspnea & Stridor" is Correct In **sudden onset** bilateral palsy, the patient experiences acute respiratory distress because the airway is almost completely obstructed. **Inspiratory stridor** occurs due to the Bernoulli effect, where the rapid flow of air through the narrow glottis sucks the cords even closer together. This is a medical emergency often requiring an urgent tracheostomy. ### Explanation of Incorrect Options * **B. Hoarseness of voice:** This is the hallmark of **unilateral** vocal cord palsy. In bilateral palsy, the cords are fixed near the midline; therefore, they can still vibrate against each other, often resulting in a **near-normal voice** despite the life-threatening airway obstruction. * **C. Asymptomatic:** While chronic, gradual bilateral palsy may allow for some compensation, "sudden onset" is never asymptomatic due to the immediate loss of the airway. * **D. Bovine cough:** This is a non-explosive cough characteristic of **unilateral** vocal cord palsy (specifically involving the Vagus nerve or recurrent laryngeal nerve), where the inability to close the glottis prevents the buildup of subglottic pressure. ### High-Yield Clinical Pearls for NEET-PG * **Most common cause:** Thyroid surgery (injury to bilateral Recurrent Laryngeal Nerves). * **Position of cords:** In bilateral abductor paralysis, cords lie in the **median/paramedian** position. * **The Paradox:** The better the voice, the worse the airway (and vice versa). * **Management:** Acute phase requires **Tracheostomy**; chronic phase may involve **Kashima’s procedure** (Laser posterior cordectomy) or Woodman’s medialization.

Q: Which is the most common site for carcinoma of the larynx?

Glottis. **Explanation:** The larynx is anatomically divided into three regions: the supraglottis, glottis, and subglottis. In the Indian subcontinent and globally, the **Glottis** (vocal cords) is the most common site for laryngeal carcinoma, accounting for approximately **60–65%** of cases. **Why Glottis is the correct answer:** * **Incidence:** The glottis is the most frequent site of origin for Squamous Cell Carcinoma (SCC) of the larynx. * **Clinical Presentation:** Glottic tumors present early with **hoarseness of voice**, leading to earlier diagnosis. * **Prognosis:** They have the best prognosis because the vocal cords have **sparse lymphatic drainage**, significantly reducing the risk of early nodal metastasis. **Analysis of Incorrect Options:** * **Suprahyoid and Infrahyoid Epiglottis (Supraglottis):** These are parts of the supraglottic larynx. Supraglottic cancers are the second most common (approx. 30–35%). Unlike glottic tumors, they have a rich lymphatic network, often presenting late with cervical lymphadenopathy. * **Subglottis:** This is the rarest site for primary laryngeal carcinoma (less than 1–2%). These tumors are often silent until they cause airway obstruction or involve the vocal cords. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factor:** Smoking is the strongest risk factor; Alcohol acts synergistically. * **Histology:** Most common type is **Squamous Cell Carcinoma (SCC)**. * **Lymphatic Drainage:** The Glottis is unique for its lack of lymphatics (Reinke’s space). * **Staging Tip:** A "fixed vocal cord" automatically upgrades a tumor to **T3** stage. * **Treatment:** Early glottic cancer (T1/T2) can be treated equally effectively with either Radiotherapy or Laser Excision.

Q: Kiss ulcer of larynx is due to:

Vocal abuse. **Explanation:** The term **"Kiss Ulcer"** in the larynx refers to a specific stage in the development of **Vocal Nodules**, which are primarily caused by **vocal abuse** (chronic voice misuse or overuse). 1. **Mechanism (Why A is correct):** Continuous vocal abuse leads to mechanical trauma at the junction of the anterior 1/3rd and posterior 2/3rd of the vocal folds (the point of maximum vibration). Initially, this causes localized edema and hemorrhage. If the trauma continues, a small breach or "ulcer" may form on one cord. Due to the constant contact during phonation, a reactive inflammatory lesion or "kissing" ulcer/nodule develops on the exactly opposite point of the contralateral vocal fold. This symmetrical presentation is the hallmark of vocal abuse. 2. **Why other options are incorrect:** * **B. Papilloma:** These are benign epithelial tumors caused by HPV (6 and 11). They present as wart-like, exophytic growths, not as symmetrical ulcers. * **C. Vocal Nodule:** While a kiss ulcer *leads* to a vocal nodule, the underlying **etiology** requested by the question is the behavior (vocal abuse). In many contexts, "Kissing Nodules" is a synonym for bilateral vocal nodules, but the primary cause remains abuse. * **D. Tuberculosis:** Laryngeal TB typically presents as a "mouse-nibbled" appearance of the vocal cords or interarytenoid pachydermia. It is usually secondary to pulmonary TB and does not follow the "kissing" pattern of mechanical trauma. **Clinical Pearls for NEET-PG:** * **Site:** Junction of anterior 1/3 and posterior 2/3 of the vocal cords. * **Synonyms:** Singer’s nodules, Teacher’s nodules, Screamer’s nodules. * **Treatment:** Conservative management (Voice rest and Speech therapy) is the first line. Surgery (Microlaryngeal surgery) is reserved for large, fibrosed nodules.

Q: What is the cadaveric position of the vocal cords?

3.5 mm from midline. ### Explanation The position of the vocal cords is determined by the balance of intrinsic laryngeal muscles. In a **cadaveric state**, all muscles (abductors, adductors, and tensors) are paralyzed. The cords settle into a neutral, passive position due to the inherent elasticity of the laryngeal tissues and the structural alignment of the cricoarytenoid joints. **1. Why 3.5 mm is correct:** The **cadaveric position** (also known as the neutral position) is characterized by the vocal cords being **3.5 mm from the midline**. This is the position seen after death or in a complete "total" laryngeal paralysis (where both the recurrent laryngeal nerve and the superior laryngeal nerve are non-functional). **2. Analysis of Incorrect Options:** * **A. Midline (0 mm):** This is the **Median position**, seen during phonation or in bilateral recurrent laryngeal nerve palsy (where the cricothyroid muscle, supplied by the superior laryngeal nerve, still acts as an adductor). * **B. 1.5 mm from midline:** This is the **Paramedian position**. It is typically seen in isolated Recurrent Laryngeal Nerve (RLN) palsy. * **D. 7.5 mm from midline:** This is the **Full Abduction position**, achieved during deep inspiration by the action of the posterior cricoarytenoid muscle (the only abductor of the vocal cords). **3. Clinical Pearls for NEET-PG:** * **Semon’s Law:** States that in progressive lesions of the RLN, the abductor fibers are injured first, causing the cord to move to the midline (adducted) before eventually reaching the cadaveric position if the paralysis becomes complete. * **Wagner and Grossman Theory:** Explains that if the Superior Laryngeal Nerve is intact, the cricothyroid muscle keeps the cord in the paramedian position; if both nerves are gone, it moves to the cadaveric position. * **Gentle Abduction:** 5 mm from midline (normal quiet breathing).

Q: A patient presented with stridor and dyspnea which developed after an upper respiratory tract infection. On examination, a 3 mm glottic opening was noted. All of the following are used in the management of this condition except?

Teflon injection. ### Explanation **Diagnosis: Bilateral Abductor Vocal Cord Paralysis** The clinical presentation of stridor and dyspnea following an upper respiratory tract infection (suggesting viral neuritis) or surgery, combined with a narrow **3 mm glottic opening**, points toward **Bilateral Abductor Vocal Cord Paralysis**. In this condition, the vocal cords are midline or paramedian, obstructing the airway while preserving voice quality. **Why Teflon Injection is the Correct Answer (The "Except"):** Teflon injection is a **medialization procedure**. It is used for **Unilateral Adductor Paralysis** (where the cord is stuck in the lateral position, causing a weak, breathy voice and aspiration risk). Injecting Teflon pushes the paralyzed cord toward the midline to improve phonation. In a patient who already has a dangerously narrow 3 mm glottic airway, medializing the cords further would lead to total airway obstruction and death. **Analysis of Other Options:** * **Tracheostomy (A):** The immediate gold standard for securing the airway in acute respiratory distress due to bilateral cord paralysis. * **Arytenoidectomy (B):** A surgical procedure to widen the posterior glottis by removing the arytenoid cartilage, improving the airway at the expense of voice quality. * **Cordectomy (D):** Specifically, **Posterior Cordectomy (Kashima’s procedure)** involves removing a portion of the vocal cord to create a larger breathing space. **NEET-PG High-Yield Pearls:** * **Woodman’s Operation:** An external approach for arytenoidectomy used in bilateral paralysis. * **Position of Cords:** In bilateral abductor palsy, the cords are in the **paramedian** position. * **Semon’s Law:** States that in progressive lesions of the recurrent laryngeal nerve, abductor fibers are injured before adductor fibers. * **Management Goal:** In bilateral paralysis, the priority is **Airway**; in unilateral paralysis, the priority is **Voice/Aspiration prevention**.

Q: In performing an elective tracheostomy, which anatomical landmark is the preferred site for tracheal entry?

Below the cricoid cartilage. ### Explanation **1. Why "Below the cricoid cartilage" is correct:** In an elective tracheostomy, the goal is to create a secure airway while avoiding long-term complications like subglottic stenosis. The preferred site for tracheal entry is between the **2nd and 3rd or 3rd and 4th tracheal rings**. This location is anatomically situated **below the cricoid cartilage**. Entering here ensures the stoma is far enough from the larynx to prevent perichondritis of the cricoid, which is the narrowest part of the upper airway. **2. Why the other options are incorrect:** * **Above the cricoid cartilage:** This area contains the thyrohyoid membrane and the thyroid notch. It is not an entry point for a tracheostomy and would interfere with laryngeal suspension. * **Through the cricothyroid membrane:** This is the site for a **Cricothyroidotomy** (Emergency Airway). While faster to perform, it is contraindicated for long-term use because it carries a high risk of subglottic stenosis due to its proximity to the vocal cords and cricoid cartilage. * **Laterally below the thyroid cartilage:** Tracheostomy must always be performed in the **midline**. A lateral approach risks injury to the recurrent laryngeal nerves, the carotid sheath, and the lobes of the thyroid gland. **3. High-Yield Clinical Pearls for NEET-PG:** * **Level of Isthmus:** The thyroid isthmus usually overlies the 2nd, 3rd, and 4th tracheal rings. It is either retracted superiorly or divided to access the trachea. * **High Tracheostomy:** Defined as being above the 2nd ring. It is generally avoided due to the risk of **subglottic stenosis**. * **Low Tracheostomy:** Below the 4th ring. It is avoided because it increases the risk of injury to the **Innominate artery** (Brachiocephalic trunk) and may lead to a tracheo-innominate fistula. * **Emergency vs. Elective:** Remember: **Cricothyroidotomy** = Emergency; **Tracheostomy** = Elective/Prolonged Intubation.

Q: Kashima operation is done for:

Bilateral vocal cord palsy. **Explanation:** **Kashima Operation (Laser Posterior Cordectomy)** is a surgical procedure primarily performed for **Bilateral Abductor Vocal Cord Palsy**. In this condition, both vocal cords remain fixed in the midline, leading to a compromised airway and inspiratory stridor. The goal of the Kashima operation is to widen the glottic chink to improve breathing while attempting to preserve voice quality. It involves using a CO2 laser to remove a wedge-shaped portion of the posterior part of one or both vocal cords (near the vocal process of the arytenoid). **Analysis of Options:** * **Bilateral Vocal Cord Palsy (Correct):** The procedure addresses the respiratory distress caused by the narrowed airway by creating a permanent posterior opening. * **Recurrent Cholesteatoma:** This is managed via mastoidectomy (Canal Wall Down or Canal Wall Up) or "Second-look" surgery, not laryngeal procedures. * **Atrophic Rhinitis:** Surgical treatments include Young’s operation or Modified Young’s operation (closing the nostrils to allow the mucosa to heal). * **Choanal Atresia:** This is managed via transnasal or transpalatal repair using endoscopes and stents. **Clinical Pearls for NEET-PG:** * **Woodman’s Operation:** Another surgery for bilateral cord palsy; it is an *extralaryngeal* approach involving arytenoidectomy. * **Key Distinction:** Kashima is an *endoscopic* (intralaryngeal) laser procedure, making it less invasive than older open techniques. * **Trade-off:** In all surgeries for bilateral cord palsy, there is a compromise: improving the **airway** often leads to a slight worsening of **voice quality** (breathiness) and an increased risk of aspiration.

Question 1

What is the advantage of flexible bronchoscopy?

Accepted Answer

All of the above

Answer

Can be performed in an awake patient

Answer

Allows examination of subsegmental bronchi

Answer

Can be used in patients with jaw and neck abnormalities

Question 2

About laryngomalacia, all are true except?

Accepted Answer

Curled epiglottis, flaccid arytenoids

Answer

Curled epiglottis, flaccid aryepiglottic fold

Answer

Flaccidity of the supraglottic larynx

Answer

Treatment is conservative

Question 3

What is the most common cause of acute laryngotracheal bronchitis?

Accepted Answer

Parainfluenza virus

Answer

Haemophilus influenzae

Answer

Influenza virus

Answer

Coxsackievirus

Question 4

Which of the following is a symptom of sudden onset bilateral vocal cord palsy?

Accepted Answer

Dyspnea & Stridor

Answer

Hoarseness of voice

Answer

Asymptomatic

Answer

Bovine cough

Question 5

Which is the most common site for carcinoma of the larynx?

Accepted Answer

Glottis

Answer

Suprahyoid epiglottis

Answer

Infrahyoid epiglottis

Answer

Subglottis

Question 6

Kiss ulcer of larynx is due to:

Accepted Answer

Vocal abuse

Answer

Papilloma

Answer

Vocal nodule

Answer

Tuberculosis

Question 7

What is the cadaveric position of the vocal cords?

Accepted Answer

3.5 mm from midline

Answer

Midline

Answer

1.5 mm from midline

Answer

7.5 mm from midline

Question 8

A patient presented with stridor and dyspnea which developed after an upper respiratory tract infection. On examination, a 3 mm glottic opening was noted. All of the following are used in the management of this condition except?

Accepted Answer

Teflon injection

Answer

Tracheostomy

Answer

Arytenoidectomy

Answer

Cordectomy

Question 9

In performing an elective tracheostomy, which anatomical landmark is the preferred site for tracheal entry?

Accepted Answer

Below the cricoid cartilage

Answer

Above the cricoid cartilage

Answer

Through the cricothyroid membrane

Answer

Laterally below the thyroid cartilage

Question 10

Kashima operation is done for:

Accepted Answer

Bilateral vocal cord palsy

Answer

Recurrent cholesteatoma

Answer

Atrophic rhinitis

Answer

Choanal atresia

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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