Diseases of the Larynx — MCQs

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 121: Juvenile papillomatoses is caused by?

A. HPV (Correct Answer)
B. EBV
C. CMV
D. HSV

Explanation: **Explanation:** **Juvenile Onset Recurrent Respiratory Papillomatosis (JORRP)** is the most common benign neoplasm of the larynx in children. It is caused by the **Human Papillomavirus (HPV)**, specifically **Types 6 and 11**. The transmission typically occurs vertically during childbirth as the fetus passes through an infected birth canal (maternal genital warts). * **Why HPV is correct:** HPV has a predilection for squamous epithelium. In the larynx, papillomas usually occur at the junction of squamous and ciliary epithelium (e.g., the vocal folds). While Types 6 and 11 are most common and usually benign, Types 16 and 18 are associated with a higher risk of malignant transformation. * **Why other options are incorrect:** * **EBV (Epstein-Barr Virus):** Primarily associated with Nasopharyngeal Carcinoma and Infectious Mononucleosis. * **CMV (Cytomegalovirus):** Typically causes congenital infections (SNHL) or opportunistic infections in immunocompromised states. * **HSV (Herpes Simplex Virus):** Causes herpetic gingivostomatitis or laryngitis but does not result in papillomatous growths. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of symptoms:** Hoarseness of voice (most common), stridor, and dyspnea. * **Characteristic finding:** "Grapelike" pedunculated masses on endoscopy. * **Treatment of choice:** CO2 Laser excision or Microdebridement. Note that total cure is difficult as the virus remains latent in the surrounding normal mucosa. * **Adjuvant therapy:** Cidofovir (antiviral) is often used in aggressive cases. * **Prevention:** The quadrivalent HPV vaccine has significantly reduced the incidence of JORRP.

Question 122: 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?

A. Tracheostomy
B. Arytenoidectomy
C. Teflon injection (Correct Answer)
D. Cordectomy

Explanation: ### 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**.

Question 123: In performing an elective tracheostomy, which anatomical landmark is the preferred site for tracheal entry?

A. Below the cricoid cartilage (Correct Answer)
B. Above the cricoid cartilage
C. Through the cricothyroid membrane
D. Laterally below the thyroid cartilage

Explanation: ### 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.

Question 124: Risk of aspiration is high in which of the following conditions?

A. Unilateral recurrent laryngeal nerve palsy
B. Bilateral recurrent laryngeal nerve palsy
C. Adductor palsy
D. Bilateral complete vocal cord palsy (Correct Answer)

Explanation: **Explanation:** The risk of aspiration is determined by the larynx's ability to act as a sphincter. The primary mechanism preventing aspiration during swallowing is the closure of the glottis (vocal cords). **Why Option D is Correct:** In **Bilateral complete vocal cord palsy** (involving both the Recurrent Laryngeal Nerve and the Superior Laryngeal Nerve), the vocal cords assume a **cadaveric position**. In this state, the cords are fixed midway between abduction and adduction. Because the cords cannot meet in the midline to seal the airway, the glottic gap remains wide open. Furthermore, the loss of the Superior Laryngeal Nerve results in **anesthesia of the supraglottic larynx**, abolishing the protective cough reflex. The combination of a wide glottic gap and sensory loss makes this the condition with the highest risk of aspiration. **Analysis of Incorrect Options:** * **A. Unilateral RLN palsy:** The healthy vocal cord can often compensate by crossing the midline to meet the paralyzed cord, maintaining a relatively effective airway seal. * **B. Bilateral RLN palsy:** The cords typically lie in a **median or paramedian position**. While this causes significant respiratory distress (stridor), the narrow glottic gap actually protects the airway from aspiration. * **C. Adductor palsy:** This is usually functional (hysterical) in nature. While it affects phonation, the cords typically adduct normally during coughing or swallowing, keeping the aspiration risk low. **High-Yield Clinical Pearls for NEET-PG:** * **Cadaveric Position:** Seen in complete palsy (RLN + SLN); cords are 3.5mm from the midline. * **Semon’s Law:** In progressive lesions, abductor fibers are injured before adductor fibers. * **Safety Muscle of Larynx:** Posterior Cricoarytenoid (the only abductor). * **Sensory Nerve of Larynx:** Internal branch of the Superior Laryngeal Nerve (above the vocal cords). Loss of this nerve is the "silent" killer in aspiration.

Question 125: Which of the following statements regarding laryngomalacia are true?

A. Most common cause of stridor in newborns
B. Omega-shaped epiglottis
C. Inspiratory stridor (Correct Answer)
D. Requires immediate surgery

Explanation: **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 (epiglottis, arytenoids, and aryepiglottic folds) during inspiration. ### **Explanation of Options** * **C. Inspiratory stridor (Correct):** The primary pathophysiology involves "floppy" supraglottic tissues. During inspiration, the negative pressure created in the airway causes these tissues to collapse into the glottic opening, resulting in a high-pitched **inspiratory stridor**. This stridor typically worsens when the infant is supine, crying, or feeding, and improves when prone. * **A. Most common cause of stridor in newborns:** While laryngomalacia is the most common cause of congenital stridor, it usually manifests at **2–4 weeks of age**, not immediately at birth. * **B. Omega-shaped epiglottis:** While an omega-shaped (Ω) epiglottis is a classic finding, it is **not present in all cases**. Diagnosis is confirmed via flexible fiberoptic laryngoscopy showing collapse of the aryepiglottic folds or redundant arytenoid mucosa. * **D. Requires immediate surgery:** Most cases (approx. 90%) are self-limiting and resolve spontaneously by 18–24 months as the laryngeal cartilage matures. Surgery (**Supraglottoplasty**) is reserved only for severe cases involving failure to thrive, cor pulmonale, or severe obstructive apnea. ### **High-Yield Clinical Pearls for NEET-PG** * **Diagnosis:** Flexible laryngoscopy is the gold standard (performed while the patient is awake). * **Associated Condition:** Gastroesophageal reflux (GERD) is frequently associated and can exacerbate the symptoms. * **Synchronous Airway Lesions:** About 10-15% of patients may have a second airway lesion (e.g., subglottic stenosis). * **Management:** Conservative (observation) is the mainstay for mild to moderate cases.

Question 126: Laryngeal papillomas are caused by which Human Papillomavirus (HPV) types?

A. 6, 11 (Correct Answer)
B. 16, 18
C. 33, 45
D. 4, 27

Explanation: **Explanation:** Laryngeal papillomatosis (also known as Recurrent Respiratory Papillomatosis or RRP) is the most common benign neoplasm of the larynx. It is caused by the **Human Papillomavirus (HPV)**, specifically **Types 6 and 11**. These are classified as "low-risk" HPV types because they primarily cause benign epithelial proliferations (warts) rather than malignancies. Type 11 is clinically significant as it is often associated with a more aggressive clinical course and more frequent recurrences. **Analysis of Options:** * **Option A (6, 11):** Correct. These types are responsible for over 90% of laryngeal papillomas in both juvenile and adult-onset forms. * **Option B (16, 18):** Incorrect. These are "high-risk" oncogenic types. While they are the primary cause of cervical cancer and oropharyngeal squamous cell carcinoma, they are rarely the primary cause of benign laryngeal papillomas. * **Option C (33, 45):** Incorrect. These are also high-risk oncogenic types associated with various anogenital and mucosal cancers. * **Option D (4, 27):** Incorrect. These types are typically associated with common cutaneous warts (Verruca vulgaris) on the hands and feet. **High-Yield Clinical Pearls for NEET-PG:** * **Bimodal Distribution:** RRP has two peaks—Juvenile (age <5, usually via vertical transmission during birth) and Adult (age 20-40). * **Classic Presentation:** Progressive hoarseness (most common) and stridor (in advanced cases). * **Morphology:** Exophytic, "cauliflower-like" sessile or pedunculated masses, most commonly on the true vocal cords. * **Treatment:** The gold standard is **CO2 Laser excision** or microdebrider excision. Note that medical therapies (e.g., Cidofovir, Interferon) are adjunctive, not curative. * **Malignant Transformation:** Rare (<3%), but when it occurs, it is often associated with HPV-16 or 18, or history of prior irradiation.

Question 127: Unilateral palsy of the external laryngeal nerve leads to what?

A. Aphonia
B. Hoarseness of voice (Correct Answer)
C. Paralysis
D. Loss of timbre of voice

Explanation: ### Explanation **1. Why "Hoarseness of voice" is correct:** The **external laryngeal nerve (ELN)** supplies the **cricothyroid muscle**, which is the primary tensor of the vocal cords. When this nerve is paralyzed (often during thyroid surgery), the cricothyroid muscle fails to contract, leading to a loss of tension in the vocal cord on the affected side. This results in an **irregularly shaped glottis** and a wavy or floppy vocal cord edge. The resulting lack of synchrony in vocal cord vibration manifests clinically as **hoarseness** and a decreased range of pitch (especially difficulty with high-pitched sounds). **2. Why the other options are incorrect:** * **Aphonia (A):** This refers to the total loss of voice. It typically occurs in bilateral recurrent laryngeal nerve palsy (where the cords are fixed in the midline/paramedian position) or functional disorders, not unilateral ELN palsy. * **Paralysis (C):** This is a general term and not a specific clinical symptom. While the cricothyroid muscle is paralyzed, the question asks for the *clinical outcome* of that palsy. * **Loss of timbre of voice (D):** While the quality of voice changes, "hoarseness" is the standard clinical descriptor used in standard ENT textbooks (like Dhingra) for unilateral ELN injury. Loss of timbre or "vocal fatigue" is more characteristic of subtle or recovering lesions. **3. High-Yield Clinical Pearls for NEET-PG:** * **The "Amateur" Nerve:** The ELN is often called the nerve of "singers" or "public speakers" because its injury prevents the fine-tuning of pitch. * **Laryngoscopy Finding:** In unilateral ELN palsy, the posterior commissure rotates toward the **paralyzed side** because of the unopposed action of the healthy contralateral cricothyroid muscle. * **Semon’s Law:** This applies to Recurrent Laryngeal Nerve (RLN) injuries, stating that abductor fibers are more susceptible to damage than adductor fibers. * **Nerve Supply Rule:** All intrinsic muscles of the larynx are supplied by the RLN **except** the cricothyroid (supplied by the ELN).

Question 128: Which of the following is WRONG regarding Laryngitis sicca?

A. Also known as Laryngitis atrophica
B. Caused by Klebsiella ozaenae
C. Caused by Rhinosporidium (Correct Answer)
D. Common in women

Explanation: ### **Explanation: Laryngitis Sicca** **Laryngitis sicca**, also known as **atrophic laryngitis**, is a chronic inflammatory condition characterized by the atrophy of the laryngeal mucosa and the crusting of secretions. #### **Why "Caused by Rhinosporidium" is the Correct (Wrong) Option:** * **Rhinosporidiosis** is caused by *Rhinosporidium seeberi* (a fish parasite/Mesomycetozoea). It typically presents as friable, leafy, strawberry-like polypoid masses in the nose or nasopharynx. It does **not** cause atrophic changes or Laryngitis sicca. * Laryngitis sicca is etiologically linked to **Klebsiella ozaenae**, the same organism responsible for atrophic rhinitis (Ozaena). #### **Analysis of Other Options:** * **Option A (Also known as Laryngitis atrophica):** This is **correct**. The disease involves the atrophy of mucus-secreting glands, leading to a dry (sicca) and withered (atrophic) appearance of the laryngeal lining. * **Option B (Caused by Klebsiella ozaenae):** This is **correct**. It is often seen in patients who already suffer from atrophic rhinitis, as the infection and crusting descend from the nose to the larynx. * **Option D (Common in women):** This is **correct**. Similar to atrophic rhinitis, this condition shows a higher predilection for females and is often associated with nutritional deficiencies (Iron, Vitamin A/D) or endocrine imbalances. --- ### **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Patients present with a dry cough, hoarseness, and the expectoration of **foul-smelling crusts** (which may cause airway obstruction). * **Triad of Atrophy:** Often co-exists with **Atrophic Rhinitis** and **Atrophic Pharyngitis** (Pharyngitis Sicca). * **Management:** Focuses on humidification, alkaline glottic washes, and removal of crusts. * **Key Differentiator:** Unlike Rhinosporidiosis (which is associated with stagnant water exposure and presents with bleeding masses), Laryngitis sicca is a disease of **mucosal dryness and crusting**.

Question 129: Which of the following are of viral origin?

A. Laryngeal papilloma
B. Nasopharyngeal carcinoma
C. Vocal nodule (Correct Answer)
D. Laryngeal web

Explanation: **Explanation** The question asks to identify which condition is **NOT** of viral origin (based on the provided answer key indicating Vocal Nodule as the correct choice). * **Vocal Nodule (Correct Answer):** This is a non-neoplastic inflammatory condition caused by **mechanical trauma** due to vocal abuse or misuse (e.g., screaming, singing). It is characterized by bilateral, symmetrical thickening at the junction of the anterior 1/3 and posterior 2/3 of the vocal cords. It has no viral etiology. * **Laryngeal Papilloma (Incorrect):** This is caused by the **Human Papillomavirus (HPV)**, specifically types 6 and 11. It is the most common benign neoplasm of the larynx in children (Juvenile Onset Recurrent Respiratory Papillomatosis). * **Nasopharyngeal Carcinoma (Incorrect):** This malignancy has a strong causal association with the **Epstein-Barr Virus (EBV)**, particularly the undifferentiated type (WHO Type 3). * **Laryngeal Web (Incorrect):** This is typically a **congenital** anomaly resulting from the failure of the laryngeal lumen to recanalize during the 10th week of gestation. While not viral, it is also not the primary "mechanical/inflammatory" condition usually contrasted with viral lesions in this context. **High-Yield Clinical Pearls for NEET-PG:** * **Vocal Nodule:** Also known as "Singer’s Nodule" or "Screamer’s Nodule." Treatment is primarily **voice therapy**; surgery is reserved for persistent cases. * **HPV 6 & 11:** Responsible for both Laryngeal Papillomatosis and Genital Warts (Condyloma Acuminata). * **EBV Markers:** IgA antibodies against Viral Capsid Antigen (VCA) are used for screening Nasopharyngeal Carcinoma. * **Laryngeal Web:** Most common site is the **glottis** (anterior commissure). Diagnosis is via direct laryngoscopy.

Question 130: A 4-year-old child presents with a history of hoarseness, croupy cough, and aphonia. The child has dyspnea with wheezing. What is the most probable diagnosis?

A. Asthmatic bronchitis
B. Laryngeal foreign body (Correct Answer)
C. Bronchopneumonia
D. Retropharyngeal abscess

Explanation: ### **Explanation** The correct diagnosis is **Laryngeal Foreign Body (FB)**. **1. Why Laryngeal Foreign Body is correct:** The clinical triad of **hoarseness, croupy cough, and aphonia** is classic for a foreign body lodged in the larynx. Unlike bronchial foreign bodies (which typically present with unilateral wheezing), laryngeal FBs cause upper airway symptoms. The presence of **dyspnea and wheezing** (stridor/audible wheeze) indicates partial airway obstruction. In a 4-year-old, sudden onset of these symptoms without a prodromal fever strongly suggests an aspirated object. **2. Why the other options are incorrect:** * **Asthmatic bronchitis:** While it causes wheezing and dyspnea, it does not typically cause **aphonia** or a **croupy cough**. It is usually associated with a history of atopy and recurrent episodes. * **Bronchopneumonia:** This presents with high-grade fever, productive cough, and toxic appearance. It does not cause sudden aphonia or a localized croupy cough. * **Retropharyngeal abscess:** This presents with **dysphagia, drooling, and neck stiffness** (torticollis). While it can cause respiratory distress, the primary symptoms are related to swallowing rather than voice loss (aphonia). **3. NEET-PG High-Yield Pearls:** * **Site of Lodgement:** The most common site for aspirated foreign bodies is the **Right Main Bronchus** (due to it being wider, shorter, and more vertical). However, laryngeal FBs are the most life-threatening. * **Jackson’s Triad for Laryngeal FB:** Hoarseness, dyspnea, and croupy cough. * **Radiology:** Most aspirated FBs are **radiolucent** (e.g., peanuts); diagnosis often relies on clinical suspicion or indirect signs like obstructive emphysema. * **Management:** The gold standard for diagnosis and removal is **Rigid Bronchoscopy** under general anesthesia. For acute complete obstruction (choking), the **Heimlich maneuver** (or back blows/chest thrusts in infants) is indicated.

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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