Diseases of the Larynx Practice Questions

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

Transient hoarseness. 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.

Q: Which of the following statements about Infraglottic carcinoma of the larynx is true?

It commonly spreads to mediastinal lymph nodes.. ### Explanation **Correct Answer: D. It commonly spreads to mediastinal lymph nodes.** **1. Why Option D is Correct:** The subglottis (infraglottic region) has a sparse lymphatic network compared to the supraglottis. However, when malignancy occurs here, the primary lymphatic drainage follows the pathway through the **cricothyroid membrane** to the **pre-laryngeal (Delphian)** and **pre-tracheal** nodes. From there, the drainage continues inferiorly into the **paratracheal** and **superior mediastinal lymph nodes**. This deep extension into the mediastinum is a characteristic feature of subglottic spread and often necessitates a mediastinal lymph node dissection during surgery. **2. Why Other Options are Incorrect:** * **Options A & B:** Glottic carcinoma (vocal cords) is the **most common** (approx. 60-65%), followed by Supraglottic carcinoma (approx. 30-35%). Subglottic (Infraglottic) carcinoma is the **rarest**, accounting for less than 5% of all laryngeal cancers. * **Option C:** Submental lymph 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 laryngeal structures. **3. High-Yield Clinical Pearls for NEET-PG:** * **Prognosis:** Subglottic cancers often present late with stridor or dyspnea because the region is clinically "silent" until the airway is compromised. They have a poorer prognosis compared to glottic cancers. * **Lymphatic Watershed:** The glottis (vocal cords) has virtually **no lymphatic drainage**, which is why early glottic cancer (T1) rarely metastasizes to the neck. * **Delphian Node:** The pre-laryngeal node is a classic "sentinel" node for subglottic and thyroid malignancies. Its involvement often indicates a higher risk of recurrence.

Q: What is the drug of choice in laryngeal stenosis?

Mitomycin C. **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.

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

Apnea due to decreased PaCO2. ### 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.

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

Isshiki type I thyroplasty. **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.

Q: 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?

Speech therapy and Proton pump inhibitor (PPI). **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.

Q: Laryngocele arises from which anatomical structure?

Saccule of the ventricle. **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.

Q: Which investigation is used for the diagnosis of laryngopharyngeal reflux?

Dual probe impedance pH monitoring. **Explanation:** **Laryngopharyngeal Reflux (LPR)**, often called "silent reflux," occurs when gastric contents reach the larynx and pharynx. Unlike GERD, LPR involves the retrograde flow of both acidic and non-acidic (pepsin, bile) material into the upper aerodigestive tract. 1. **Why Option B is Correct:** **Dual probe multichannel intraluminal impedance (MII) pH monitoring** is the **Gold Standard** for diagnosing LPR. * **Dual Probe:** One sensor is placed in the distal esophagus (to detect GERD) and the second is placed in the hypopharynx (to detect LPR). * **Impedance:** Unlike traditional pH probes that only detect acid (pH < 4), impedance can detect **non-acidic and gaseous reflux**, which is common in LPR patients who often do not respond to standard PPI therapy. 2. **Why other options are incorrect:** * **A. Esophageal pH monitoring:** This uses a single probe in the distal esophagus. While excellent for GERD, it cannot confirm if the refluxate has reached the laryngeal level. * **C. Barium esophagram:** This is a structural study used to identify anatomical abnormalities (strictures, webs, or hiatal hernias) but has very low sensitivity for detecting intermittent reflux episodes. * **D. Scintigraphy:** This involves swallowing radioactive isotopes. While it can detect aspiration, it is not a standard diagnostic tool for LPR due to poor sensitivity and lack of standardized protocols. **Clinical Pearls for NEET-PG:** * **Most common symptom of LPR:** Globus pharyngeus (sensation of a lump in the throat). * **Most common sign on Laryngoscopy:** Interarytenoid erythema/pachydermia and pseudosulcus vocalis. * **Reflux Finding Score (RFS):** A clinical tool used during laryngoscopy to quantify the severity of LPR. * **Treatment:** LPR requires more aggressive treatment than GERD, often requiring twice-daily (BID) PPIs for 3–6 months.

Q: Which is the narrowest part of the larynx in children?

Subglottic. **Explanation:** The larynx undergoes significant anatomical changes during development. In children (infants and young children), the **Subglottic region** (specifically at the level of the **Cricoid cartilage**) is the narrowest part of the airway. **1. Why Subglottic is Correct:** In pediatric anatomy, the larynx is shaped like a **funnel** or a cone. The cricoid cartilage is the only complete cartilaginous ring in the respiratory tract. Because it is a rigid, non-expandable circle, any mucosal edema in this region significantly compromises the airway. This is the physiological basis for why **Croup (Laryngotracheobronchitis)** is so dangerous in children. **2. Why other options are incorrect:** * **Glottic region (Option C):** In **adults**, the glottis (the space between the vocal cords) is the narrowest part. As a child matures, the larynx transitions from a funnel shape to a **cylindrical** shape, shifting the narrowest point upward to the glottis. * **Supraglottic (Option A):** This area is wider and more distensible; while it can be affected by infections (like Epiglottitis), it is not the narrowest anatomical point. **Clinical Pearls for NEET-PG:** * **Shape:** Pediatric larynx is **funnel-shaped**; Adult larynx is **cylindrical**. * **Position:** The pediatric larynx is higher in the neck (at the level of **C3-C4**) compared to adults (**C4-C6**). * **Poiseuille’s Law:** Because the subglottis is the narrowest point, 1 mm of edema reduces the cross-sectional area by approximately 75% in an infant, compared to only 44% in an adult. * **Uncuffed Tubes:** Historically, uncuffed endotracheal tubes were preferred in children to prevent pressure necrosis at the narrow cricoid level (though modern practice is evolving).

Q: Mouse nibbled appearance of vocal cords is seen in:

Tuberculous laryngitis. **Explanation:** **Tuberculous Laryngitis (Correct Answer):** Laryngeal tuberculosis is usually secondary to pulmonary tuberculosis (via infected sputum). The "mouse-nibbled" appearance refers to the **irregular, ragged ulcerations** seen on the margins of the vocal cords. These ulcers are typically shallow and pale. The posterior part of the larynx (interarytenoid fold, arytenoids, and posterior vocal cords) is the most common site involved. Patients often present with severe odynophagia (painful swallowing) and hoarseness. **Why other options are incorrect:** * **Syphilis:** Laryngeal syphilis typically presents with a "punched-out" ulcer or a gumma. It is characterized by a dusky red appearance and is generally painless, unlike tuberculosis. * **Achalasia Cardia:** This is a motility disorder of the esophagus, not the larynx. While it may cause aspiration pneumonia or nocturnal cough, it does not produce vocal cord ulcerations. * **Lupus (Lupus Vulgaris):** This is a chronic form of cutaneous tuberculosis. When it affects the larynx, it usually involves the epiglottis and presents with a "turban-shaped" epiglottis due to edema and thickening, rather than nibbled cord margins. **Clinical Pearls for NEET-PG:** * **Most common site of Laryngeal TB:** Posterior commissure (Interarytenoid area). * **Pain:** The pain in laryngeal TB is often referred to the ear via the Arnold’s nerve (Vagus). * **Turban Epiglottis:** Seen in Lupus Vulgaris or advanced Laryngeal TB. * **Management:** Primarily medical (Anti-Tubercular Therapy). Vocal rest is essential.

Question 1

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

Accepted Answer

Transient hoarseness

Answer

Dyspnea on exertion

Answer

Husky voice

Answer

Inspiratory stridor

Question 2

Which of the following statements about Infraglottic carcinoma of the larynx is true?

Accepted Answer

It commonly spreads to mediastinal lymph nodes.

Answer

It is the most common carcinoma of the larynx.

Answer

It is the second most common carcinoma of the larynx.

Answer

It commonly spreads to submental lymph nodes.

Question 3

What is the drug of choice in laryngeal stenosis?

Accepted Answer

Mitomycin C

Answer

Cyclophosphamide

Answer

Doxorubicin

Answer

Adriamycin

Question 4

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

Accepted Answer

Apnea due to decreased PaCO2

Answer

Tracheal stenosis

Answer

Tracheocutaneous fistula

Answer

Tracheoesophageal fistula

Question 5

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

Accepted Answer

Isshiki type I thyroplasty

Answer

Isshiki type II thyroplasty

Answer

Woodman operation

Answer

Laser arytenoidectomy

Question 6

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?

Accepted Answer

Speech therapy and Proton pump inhibitor (PPI)

Answer

Microlaryngoscopic surgery and CO2 laser

Answer

Microlaryngectomy

Answer

Direct laryngoscopy and biopsy

Question 7

Laryngocele arises from which anatomical structure?

Accepted Answer

Saccule of the ventricle

Answer

Anterior commissure

Answer

True vocal cords

Answer

False vocal cords

Question 8

Which investigation is used for the diagnosis of laryngopharyngeal reflux?

Accepted Answer

Dual probe impedance pH monitoring

Answer

Esophageal pH monitoring

Answer

Barium esophagram

Answer

Scintigraphy

Question 9

Which is the narrowest part of the larynx in children?

Accepted Answer

Subglottic

Answer

Supraglottic

Answer

Glottic region

Answer

None

Question 10

Mouse nibbled appearance of vocal cords is seen in:

Accepted Answer

Tuberculous laryngitis

Answer

Syphilis

Answer

Achalasia Cardia

Answer

Lupus

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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