Diseases of the Larynx — MCQs

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 131: Which of the following are premalignant conditions for carcinoma of the larynx?

A. Leukoplakia
B. Lichen planus
C. Papillomas
D. Chronic laryngitis (Correct Answer)

Explanation: **Explanation:** The correct answer is **Chronic laryngitis**. In the context of laryngeal pathology, chronic irritation leads to cellular changes that predispose the epithelium to malignancy. 1. **Why Chronic Laryngitis is correct:** Chronic hypertrophic laryngitis, particularly when associated with long-term smoking and alcohol abuse, leads to **keratosis** and **dysplasia**. While "chronic laryngitis" is a broad term, it is clinically recognized as the precursor state where persistent inflammation triggers the progression from hyperplasia to carcinoma in situ and, eventually, invasive squamous cell carcinoma. 2. **Analysis of Incorrect Options:** * **Leukoplakia:** While often considered premalignant, leukoplakia is a *clinical description* (a white patch) rather than a specific pathological diagnosis. Many sources consider it a feature of chronic laryngitis rather than a separate disease entity in the larynx. * **Lichen planus:** This is an inflammatory mucocutaneous condition. While it has a known premalignant potential in the **oral cavity**, it is extremely rare in the larynx and is not a standard precursor for laryngeal cancer. * **Papillomas:** Adult-onset papillomas are caused by HPV (Types 6 and 11). While they can recur frequently, they are generally considered benign. Malignant transformation is rare unless there is a history of prior radiation therapy or co-infection with high-risk HPV types (16/18). **High-Yield Pearls for NEET-PG:** * **Most common site** for laryngeal cancer: Glottis (True vocal cords). * **Most common histological type:** Squamous cell carcinoma (>95%). * **Pachydermia Laryngis:** A form of chronic hypertrophic laryngitis affecting the posterior commissure; it is generally **not** considered premalignant. * **Keratosis with Dysplasia:** This is the single most important histological predictor of malignant transformation in the laryngeal mucosa.

Question 132: All are true regarding laryngomalacia except:

A. Poor prognosis (Correct Answer)
B. Most common congenital anomaly of the larynx
C. Stridor
D. Gets relieved in prone position

Explanation: **Explanation:** Laryngomalacia is the **most common congenital anomaly of the larynx** and the most frequent cause of congenital stridor in infants. It is characterized by an inward collapse of the supraglottic structures (epiglottis, aryepiglottic folds) during inspiration due to abnormal flaccidity. **Why "Poor Prognosis" is the correct answer (the false statement):** Laryngomalacia generally has an **excellent prognosis**. In the vast majority of cases (approx. 90%), it is a self-limiting condition that resolves spontaneously by the age of 18–24 months as the laryngeal cartilage matures and hardens. Surgical intervention (Supraglottoplasty) is reserved only for severe cases involving failure to thrive or cor pulmonale. **Analysis of other options:** * **Most common congenital anomaly:** It accounts for nearly 60-70% of all congenital laryngeal problems. * **Stridor:** The hallmark clinical feature is **inspiratory stridor**, which typically appears within the first two weeks of life. * **Relieved in prone position:** The stridor characteristically worsens when the infant is supine, crying, or feeding, and is **relieved when the infant is placed in the prone position** or with the neck extended, as gravity helps pull the supraglottic structures forward. **Clinical Pearls for NEET-PG:** * **Omega-shaped epiglottis:** The classic endoscopic finding due to the folding of the epiglottis. * **Diagnosis:** Flexible fiberoptic laryngoscopy is the gold standard (shows inward collapse of aryepiglottic folds). * **Associated condition:** Gastroesophageal reflux (GERD) is frequently associated and can worsen the symptoms. * **Management:** Reassurance and observation are the primary treatments for mild to moderate cases.

Question 133: What is the symptom of a person with unilateral abductor paralysis of the vocal cords?

A. Dyspnea on exertion
B. Transient hoarseness (Correct Answer)
C. Husky voice
D. Inspiratory stridor

Explanation: In **unilateral abductor paralysis**, the affected vocal cord lies in the **median or paramedian position** because the adductors (lateral cricoarytenoid and interarytenoid) are still functional, while the abductor (posterior cricoarytenoid) is paralyzed. ### Why "Transient Hoarseness" is Correct: When one cord is paralyzed in the midline, the healthy vocal cord can still cross the midline to meet the paralyzed one. This **compensatory mechanism** allows for adequate glottic closure during phonation. Initially, the patient may experience mild hoarseness due to the sudden change in tension and position, but this is **transient** as the contralateral cord compensates quickly. Because the airway remains half-open, the respiratory function is usually unaffected. ### Explanation of Incorrect Options: * **A. Dyspnea on exertion:** This is typically absent because one vocal cord is in the midline and the other abducts normally, leaving a sufficient glottic gap for quiet and even mildly strenuous breathing. * **C. Husky voice:** A husky or breathy voice is characteristic of **unilateral adductor paralysis** (where the cord is stuck in the lateral/abducted position), leading to a large glottic gap and air wastage. * **D. Inspiratory stridor:** This is the hallmark of **bilateral abductor paralysis**, where both cords lie in the midline, severely narrowing the airway. ### NEET-PG Clinical Pearls: * **Most common cause:** Trauma (specifically Thyroid surgery injuring the Recurrent Laryngeal Nerve). * **Position of cords:** In unilateral RLN palsy, the cord is **paramedian** (Semon’s Law). * **Bilateral Abductor Paralysis:** This is a surgical emergency requiring tracheostomy because the airway is compromised, though the **voice remains remarkably good**. * **Unilateral Adductor Paralysis:** Rare as an isolated finding; usually seen in combined RLN and Superior Laryngeal Nerve lesions.

Question 134: What is the drug of choice in laryngeal stenosis?

A. Cyclophosphamide
B. Doxorubicin
C. Adriamycin
D. Mitomycin C (Correct Answer)

Explanation: **Explanation:** **Laryngeal stenosis** is characterized by the narrowing of the airway due to the formation of excessive fibrous scar tissue (fibroblasts). The primary challenge in surgical management is the high rate of recurrence due to postoperative scarring. **Why Mitomycin C is the Correct Answer:** Mitomycin C is an antineoplastic antibiotic derived from *Streptomyces caespitosus*. In the context of ENT, it is used **topically** as an anti-proliferative agent. It acts by inhibiting DNA synthesis and, most importantly, **inhibiting fibroblast proliferation and migration**. When applied to the site of a laryngeal web or stenosis after surgical dilation or excision, it significantly reduces collagen synthesis and prevents the formation of new scar tissue, thereby maintaining the patency of the airway. **Analysis of Incorrect Options:** * **A. Cyclophosphamide:** An alkylating agent primarily used in systemic chemotherapy or for autoimmune conditions like Wegener’s Granulomatosis (which can cause subglottic stenosis), but it is not the drug of choice for treating the stenosis itself. * **B. Doxorubicin & C. Adriamycin:** These are the same drug (Adriamycin is a brand name). It is an anthracycline chemotherapy agent used for systemic malignancies. It does not have a recognized topical role in preventing airway scarring. **Clinical Pearls for NEET-PG:** * **Application:** Mitomycin C is typically applied topically using a soaked cotton pledget (concentration: 0.4 mg/ml to 1 mg/ml) for 2–5 minutes. * **Other Uses in ENT:** It is also used to maintain patency in **Choanal Atresia** surgery and **Dacryocystorhinostomy (DCR)**. * **Most common site:** The subglottis is the most common site of laryngeal stenosis (Subglottic Stenosis), often secondary to prolonged intubation.

Question 135: Which of the following is NOT a long-term complication of tracheostomy?

A. Tracheal stenosis
B. Tracheocutaneous fistula
C. Tracheoesophageal fistula
D. Apnea due to decreased PaCO2 (Correct Answer)

Explanation: ### Explanation The complications of tracheostomy are clinically categorized into **Immediate** (during surgery), **Intermediate/Early** (within hours to days), and **Late/Long-term** (weeks to months). #### Why Option D is the Correct Answer **Apnea due to decreased PaCO2** is an **immediate complication** of tracheostomy. In patients with chronic airway obstruction (like laryngeal tumors), the body becomes accustomed to high levels of $CO_2$ (hypercapnia). The respiratory center becomes insensitive to $CO_2$, and breathing is driven by hypoxia (hypoxic drive). When a tracheostomy is performed, the sudden washout of $CO_2$ and rapid increase in $O_2$ removes this hypoxic drive, leading to sudden apnea. This occurs on the operating table or immediately post-procedure, not as a long-term event. #### Analysis of Incorrect Options (Long-term Complications) * **A. Tracheal Stenosis:** The most common long-term complication. It usually occurs at the site of the stoma or the tracheostomy tube cuff due to pressure necrosis and subsequent fibrosis. * **B. Tracheocutaneous Fistula:** Occurs when the epithelial lining of the trachea becomes continuous with the skin after the tube is removed, preventing the stoma from closing spontaneously. * **C. Tracheoesophageal Fistula:** A late complication caused by pressure necrosis of the posterior tracheal wall (often due to an over-inflated cuff) and the anterior esophageal wall. #### High-Yield Clinical Pearls for NEET-PG * **Most common immediate complication:** Hemorrhage (usually from the anterior jugular veins or thyroid isthmus). * **Most common late complication:** Tracheal stenosis. * **Tracheoinnominate Artery Fistula:** A rare but fatal late complication (usually occurs within 3 weeks) presenting with massive "herald" bleeds. * **Management of Post-Tracheostomy Apnea:** Provide respiratory support (ventilator) and administer 5% $CO_2$ to stimulate the respiratory center.

Question 136: What is the primary function of the larynx?

A. Speech production
B. Protection of the airway
C. Conduit for air passage
D. All of the above (Correct Answer)

Explanation: ### Explanation The larynx, often referred to as the "watchdog of the air passages," is a complex organ with multiple vital functions. While it is commonly associated with voice, its primary evolutionary and physiological roles are protective. **1. Protection of the Airway (The Most Vital Function):** This is the most primitive and essential function. During swallowing, the larynx acts as a sphincter to prevent aspiration. This is achieved through three levels of closure: the aryepiglottic folds, the false vocal cords (ventricular bands), and the true vocal cords. The cough reflex, initiated by laryngeal stimulation, further clears any foreign matter. **2. Conduit for Air Passage:** The larynx serves as a rigid patency-maintaining tube within the respiratory tract. By regulating the size of the glottis (the space between the vocal cords), it controls airflow into the lungs and assists in the regulation of acid-base balance by adjusting CO2 elimination. **3. Speech Production (Phonation):** The larynx acts as a transducer, converting the expiratory blast of air into sound (voice) through the vibration of the true vocal cords. This sound is then modulated by the resonators (pharynx, mouth, nose) to produce speech. **Why "All of the Above" is Correct:** While protection is the *most important* function for survival, the larynx simultaneously serves as a respiratory conduit and the organ of phonation. Therefore, all three options are primary functions of the larynx. ### Clinical Pearls for NEET-PG: * **Sphincteric Action:** The **aryepiglottic folds** are the first line of defense during swallowing. * **Inlet of Larynx:** It is bounded anteriorly by the epiglottis, laterally by aryepiglottic folds, and posteriorly by the interarytenoid fold. * **High-Yield Fact:** If a question asks for the **"most important"** or **"most primitive"** function of the larynx, the answer is **Protection of the lower airway**. * **Effort Closure:** During activities like lifting heavy weights (Valsalva maneuver), the larynx closes to trap air in the lungs, providing a stable thoracic cage.

Question 137: Treatment for unilateral vocal cord palsy includes which of the following procedures?

A. Isshiki type I thyroplasty (Correct Answer)
B. Isshiki type II thyroplasty
C. Woodman operation
D. Laser arytenoidectomy

Explanation: **Explanation:** The primary goal in treating **unilateral vocal cord palsy** is to improve voice quality by moving the paralyzed cord to the midline so the healthy cord can make contact (medialization). **Why Option A is Correct:** **Isshiki Type I Thyroplasty** is a **medialization laryngoplasty**. It involves creating a window in the thyroid cartilage and placing an implant (e.g., Silastic or Gore-Tex) to push the paralyzed vocal cord toward the midline. This allows for better glottic closure during phonation, effectively treating the breathy dysphonia associated with unilateral palsy. **Why Other Options are Incorrect:** * **Isshiki Type II Thyroplasty:** This is a **lateralization** procedure used for Spasmodic Dysphonia (Adductor type) to move the cords apart and reduce voice strain. * **Woodman Operation & Laser Arytenoidectomy (Options C & D):** These are **lateralization procedures** used to treat **bilateral abductor palsy**. In bilateral palsy, the airway is compromised because the cords are stuck in the midline; therefore, the goal is to move them apart to improve breathing, which is the opposite of what is needed for unilateral palsy. **High-Yield Clinical Pearls for NEET-PG:** * **Isshiki Classification of Thyroplasty:** * **Type I:** Medialization (for Unilateral Palsy). * **Type II:** Lateralization (for Spasmodic Dysphonia). * **Type III:** Relaxation/Shortening (to lower pitch). * **Type IV:** Stretching/Tension (to raise pitch, e.g., in Androphonia/Puberphonia). * **Wait and Watch:** For unilateral palsy, definitive surgery is usually delayed for **6–12 months** to allow for spontaneous recovery, unless the cause is known to be permanent (e.g., nerve transection). * **Gelfoam Injection:** A temporary medialization technique used if recovery is expected.

Question 138: A 30-year-old female with a history of singing, vocal abuse, and gastroesophageal reflux developed nodules at the junction of the anterior one-third and middle one-third of her vocal cords. What is the treatment of choice?

A. Speech therapy and Proton pump inhibitor (PPI) (Correct Answer)
B. Microlaryngoscopic surgery and CO2 laser
C. Microlaryngectomy
D. Direct laryngoscopy and biopsy

Explanation: **Explanation:** The clinical presentation describes **Vocal Nodules** (also known as Singer’s or Screamer’s nodules). These are benign, inflammatory callous-like thickenings that typically occur bilaterally at the **junction of the anterior 1/3 and posterior 2/3** (the mid-point of the membranous cord), which is the area of maximum vibratory amplitude. **Why Option A is Correct:** The primary etiology of vocal nodules is chronic vocal abuse/misuse. In this patient, the history of singing and vocal abuse, compounded by GERD (which causes laryngeal irritation), confirms the diagnosis. The **first-line treatment** for vocal nodules is always conservative: 1. **Speech/Voice Therapy:** To correct faulty vocal habits and reduce trauma to the cords. 2. **Medical Management:** Treating aggravating factors like GERD with PPIs. Most nodules, especially early/soft ones, regress with these measures. **Why Other Options are Incorrect:** * **Options B & C (Surgical intervention):** Microlaryngoscopic surgery (MLS) or CO2 laser excision is reserved only for large, chronic, or "fibrotic" nodules that fail to respond to a minimum of 3–6 months of conservative therapy. Surgery without voice therapy often leads to recurrence. * **Option D (Biopsy):** Vocal nodules have a characteristic appearance and history; a biopsy is generally unnecessary unless there is a suspicion of malignancy (which is rare in a young, non-smoking female with bilateral lesions). **High-Yield Clinical Pearls for NEET-PG:** * **Site:** Junction of anterior 1/3 and posterior 2/3 (membranous part). * **Nature:** Usually bilateral and symmetrical. * **Histology:** Early nodules are edematous; late nodules are fibrotic/hyalinized. * **Vocal Polyps vs. Nodules:** Polyps are usually unilateral, often follow a single episode of vocal trauma, and more frequently require surgical excision compared to nodules.

Question 139: Laryngocele arises from which anatomical structure?

A. Anterior commissure
B. Saccule of the ventricle (Correct Answer)
C. True vocal cords
D. False vocal cords

Explanation: **Explanation:** **Laryngocele** is an abnormal cystic dilatation of the **saccule of the laryngeal ventricle**. The saccule (or appendix of the ventricle) is a blind pouch containing mucous glands, located between the false vocal cords and the inner aspect of the thyroid cartilage. When the neck of this saccule becomes obstructed (due to inflammation or tumors) or subjected to increased intralaryngeal pressure (e.g., in trumpet players or glassblowers), it distends with air, forming a laryngocele. **Analysis of Options:** * **Option B (Correct):** The saccule is the anatomical origin. If it contains air, it is a laryngocele; if it fills with mucus, it is a **laryngopyocele**. * **Option A (Anterior commissure):** This is the junction where the two vocal cords meet anteriorly. It is a critical landmark for tumor spread (Broyle’s ligament) but not the site of origin for laryngoceles. * **Options C & D (True and False Vocal Cords):** While the ventricle lies *between* the true and false cords, the laryngocele specifically arises from the saccule extending superiorly from the ventricle, not the cords themselves. **High-Yield Clinical Pearls for NEET-PG:** 1. **Types:** * **Internal:** Confined to the larynx (presents with hoarseness/stridor). * **External:** Pierces the **thyrohyoid membrane** (presents as a neck mass that expands with the Valsalva maneuver). * **Combined:** Features of both. 2. **Bryce’s Sign:** Gurgling sound heard on compression of the external swelling. 3. **Radiology:** CT scan is the gold standard, showing an air-filled sac. 4. **Association:** In adults, always rule out **Squamous Cell Carcinoma** of the ventricle obstructing the saccule orifice.

Question 140: What is the main treatment for congenital laryngeal stridor?

A. Tracheostomy
B. Steroid therapy
C. Reassurance to the child's parents (Correct Answer)
D. Amputation of the epiglottis

Explanation: **Explanation:** **Congenital laryngeal stridor**, also known as **Laryngomalacia**, is the most common cause of congenital stridor and the most frequent congenital anomaly of the larynx. It is characterized by an inward collapse of the supraglottic structures (omega-shaped epiglottis, short aryepiglottic folds) during inspiration. **Why Reassurance is the Correct Answer:** In the vast majority of cases (approx. 90%), laryngomalacia is a **self-limiting condition**. The stridor typically appears at birth or within the first few weeks of life, peaks at 6–9 months, and resolves spontaneously by 18–24 months as the laryngeal cartilage matures and strengthens. Therefore, the primary management is conservative, involving **reassurance to the parents** and monitoring the child's growth and weight gain. **Why Other Options are Incorrect:** * **Tracheostomy:** This is a radical intervention reserved only for life-threatening airway obstruction or severe cor pulmonale, which is rare in simple laryngomalacia. * **Steroid Therapy:** Laryngomalacia is a structural/mechanical issue, not an inflammatory one; hence, steroids have no role in routine management. * **Amputation of the Epiglottis:** This is an obsolete and dangerous procedure. Modern surgical intervention (if required for severe cases with "failure to thrive") is **Supraglottoplasty**, which involves trimming the aryepiglottic folds. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** Inspiratory stridor that **increases** when the child is supine, crying, or feeding, and **decreases** when the child is prone (on the belly). * **Diagnosis:** Flexible fiberoptic laryngoscopy is the gold standard (shows "Omega-shaped" epiglottis). * **Associated Condition:** Gastroesophageal reflux (GERD) is frequently associated and can worsen the stridor; treating GERD often improves symptoms.

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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