Diseases of the Larynx — MCQs

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 141: Which investigation is used for the diagnosis of laryngopharyngeal reflux?

A. Esophageal pH monitoring
B. Dual probe impedance pH monitoring (Correct Answer)
C. Barium esophagram
D. Scintigraphy

Explanation: **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.

Question 142: Mouse nibbled appearance of vocal cords is seen in:

A. Tuberculous laryngitis (Correct Answer)
B. Syphilis
C. Achalasia Cardia
D. Lupus

Explanation: **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 143: Which part of the larynx shows the highest lymph node involvement in carcinoma?

A. Glottic carcinoma
B. Subglottic carcinoma
C. Supraglottic carcinoma (Correct Answer)
D. Equal incidence in all locations

Explanation: ### Explanation The correct answer is **Supraglottic carcinoma**. The incidence of lymph node metastasis in laryngeal cancer is directly proportional to the density of the lymphatic capillary network in that specific anatomical site. **1. Why Supraglottic Carcinoma is Correct:** The supraglottis (epiglottis, aryepiglottic folds, false cords) possesses an **extremely rich and dense network of lymphatic vessels**. These vessels pierce the thyrohyoid membrane to drain into the deep cervical (Level II, III, and IV) nodes. Approximately **40–50%** of patients with supraglottic SCC present with clinically palpable nodes at the time of diagnosis, and bilateral spread is common due to the midline nature of structures like the epiglottis. **2. Why Other Options are Incorrect:** * **Glottic Carcinoma:** The vocal cords (glottis) have **virtually no lymphatic drainage** (Reinke’s space acts as a barrier). Consequently, lymph node metastasis is extremely rare (<1%) in early glottic cancer. This is why glottic cancers have the best prognosis. * **Subglottic Carcinoma:** While the subglottis has a moderate lymphatic supply (draining to paratracheal and prelaryngeal/Delphian nodes), it is a rare site for primary tumors. The incidence of nodal involvement (approx. 20%) is significantly lower than in supraglottic lesions. * **Equal Incidence:** This is incorrect because of the stark anatomical differences in lymphatic density described above. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of laryngeal cancer:** Glottis (but lowest nodal spread). * **Best prognosis:** Glottic cancer (due to early symptoms like hoarseness and poor lymphatics). * **Worst prognosis:** Subglottic cancer (often diagnosed late and spreads to paratracheal nodes). * **Delphian Node:** The prelaryngeal node; its involvement often suggests subglottic or thyroid extension. * **Most common histology:** Squamous Cell Carcinoma (SCC) (>95%).

Question 144: What is the anatomical location of Reinke's space in the larynx?

A. False vocal cord
B. True vocal cord (Correct Answer)
C. Prelaryngeal space
D. Retropharyngeal space

Explanation: **Explanation:** **Reinke’s space** is a potential subepithelial space located in the **true vocal cords**. Anatomically, it lies between the overlying squamous epithelium and the underlying vocal ligament. It is filled with loose, gelatinous connective tissue (the superficial lamina propria) and lacks lymphatic drainage, which explains why edema in this region persists for long periods. **Why the other options are incorrect:** * **False vocal cord (Vestibular fold):** These are located superior to the true vocal cords. While they contain loose connective tissue and glands, they do not contain the specific anatomical arrangement known as Reinke’s space. * **Prelaryngeal space:** This is an extrinsic space located in front of the larynx, containing the prelaryngeal (Delphian) lymph nodes. * **Retropharyngeal space:** This is a potential space located behind the pharynx, extending from the skull base to the mediastinum; it is not an intrinsic laryngeal space. **High-Yield Clinical Pearls for NEET-PG:** * **Reinke’s Edema:** Characterized by bilateral, diffuse swelling of the vocal cords due to fluid accumulation in Reinke’s space. * **Etiology:** Strongly associated with **chronic smoking** and vocal abuse. It typically presents as a low-pitched, "husky" voice (often in middle-aged females). * **Boundaries:** Reinke’s space is limited superiorly and inferiorly by the attachment of the epithelium to the vocal ligament (linea alba). * **Management:** Smoking cessation is mandatory; surgical management involves a "decortication" or "stripping" of the vocal cord (Hirano’s microflap technique).

Question 145: What is true about Ackermans tumor?

A. It is a highly malignant tumor
B. It is verrucous carcinoma of the larynx (Correct Answer)
C. Radiotherapy is the treatment of choice
D. It spreads via lymphatics in the early stage

Explanation: **Explanation:** **Ackerman’s Tumor**, also known as **Verrucous Carcinoma**, is a specific, well-differentiated variant of squamous cell carcinoma. It typically presents as a slow-growing, exophytic, "wart-like" or cauliflower-like mass, most commonly involving the vocal cords. * **Why Option B is correct:** Ackerman’s tumor is the eponymous name for verrucous carcinoma. It is characterized histologically by a "pushing" rather than an "infiltrating" margin, with minimal cellular atypia. * **Why Option A is incorrect:** Despite its bulky appearance, it is a **low-grade**, locally aggressive tumor with a very low potential for distant metastasis. It is considered "clinically malignant but histologically benign-looking." * **Why Option C is incorrect:** **Surgery** (wide local excision) is the treatment of choice. Radiotherapy is generally avoided because it is relatively radioresistant and carries a risk of inducing **anaplastic transformation** into a highly aggressive spindle cell carcinoma. * **Why Option D is incorrect:** A hallmark of Ackerman’s tumor is that it **rarely spreads to regional lymph nodes**. Lymphadenopathy, if present, is usually reactive/inflammatory rather than metastatic. **High-Yield Clinical Pearls for NEET-PG:** * **Appearance:** "Chewing gum" or "Cauliflower" appearance. * **Common Site:** Glottis (Larynx) and Oral Cavity (associated with tobacco chewing). * **Histology:** Characterized by "church-spire" keratosis and a "pushing" border. * **Prognosis:** Excellent if surgically excised, as it does not metastasize.

Question 146: Rienke's edema is seen in which of the following locations?

A. Vestibular folds
B. Vocal cords (Correct Answer)
C. Between true and false vocal cords
D. Piriform fossa

Explanation: **Explanation:** **Reinke’s edema** is a clinical condition characterized by the accumulation of gelatinous fluid in the **Reinke’s space**, which is a potential space located in the **vocal cords**. 1. **Why Option B is Correct:** The vocal cord consists of several layers. Reinke’s space is the **superficial lamina propria** of the vocal fold, situated between the squamous epithelium and the vocal ligament. Because this space has sparse lymphatic drainage, fluid accumulates easily here, leading to diffuse swelling of the true vocal cords. This is typically seen in chronic smokers and individuals who misuse their voice. 2. **Why Other Options are Incorrect:** * **A. Vestibular folds:** Also known as false vocal cords, these are located superior to the true vocal cords. While they can be involved in inflammatory conditions, they do not contain Reinke’s space. * **C. Between true and false vocal cords:** This anatomical area is the **Laryngeal Ventricle (Sinus of Morgagni)**. It is a site for laryngoceles but not Reinke’s edema. * **D. Piriform fossa:** This is a part of the hypopharynx (laryngopharynx), not the endolarynx. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Strongly associated with **chronic smoking** and vocal abuse. It is more common in middle-aged women. * **Clinical Feature:** Characterized by a **low-pitched, husky voice** (often described as a "masculine voice" in females). * **Appearance:** Bilateral, symmetrical, pale, fusiform swellings of the true vocal cords that "jiggle" during phonation. * **Treatment:** Smoking cessation is mandatory. Definitive treatment involves **Decortication** (stripping of the vocal cord mucosa) or "Squeezing out" the fluid via a microlaryngeal surgery (Kirstein’s flap).

Question 147: Respiratory compromise is typically seen in which condition?

A. Bilateral recurrent laryngeal nerve palsy (Correct Answer)
B. Superior and recurrent laryngeal nerve palsy
C. Incomplete unilateral recurrent laryngeal nerve palsy
D. Complete unilateral recurrent laryngeal nerve palsy

Explanation: **Explanation:** The primary function of the **Recurrent Laryngeal Nerve (RLN)** is to supply all intrinsic muscles of the larynx except the cricothyroid. Crucially, it supplies the **posterior cricoarytenoid (PCA)**, which is the sole abductor of the vocal cords. **1. Why Option A is Correct:** In **Bilateral Recurrent Laryngeal Nerve Palsy**, both vocal cords lose their ability to abduct. According to **Semon’s Law**, the abductor fibers are more vulnerable than adductor fibers. Consequently, the cords assume a **median or paramedian position**. This significantly narrows the glottic chink, leading to acute **respiratory compromise** and inspiratory stridor, often necessitating an emergency tracheostomy. **2. Why the Incorrect Options are Wrong:** * **Option B:** In combined palsy (Superior + Recurrent), the cricothyroid (tenser) is also paralyzed. This results in a "cadaveric" position (mid-way between midline and lateral). While the voice is very breathy, the airway remains adequate. * **Option C & D:** In **Unilateral RLN Palsy** (complete or incomplete), the unaffected vocal cord can usually compensate by crossing the midline to meet the paralyzed cord. While this causes hoarseness of voice, the airway remains patent, and there is no respiratory distress. **High-Yield Clinical Pearls for NEET-PG:** * **Semon’s Law:** In progressive lesions of the RLN, abductor fibers are damaged before adductor fibers. * **Wagner and Grossman Theory:** The cricothyroid muscle (supplied by the Superior Laryngeal Nerve) keeps the cord in a paramedian position even if the RLN is out. * **Most common cause of Bilateral RLN Palsy:** Thyroid surgery (total thyroidectomy). * **Management:** Emergency tracheostomy for airway; later, lateralization of the cord (e.g., Woodman’s operation).

Question 148: Topical mitomycin-C is used in which of the following conditions?

A. Sturge-Weber syndrome
B. Laryngotracheal stenosis (Correct Answer)
C. Endoscopic angiofibroma
D. Skull base osteomyelitis

Explanation: **Explanation:** **Laryngotracheal Stenosis (Correct Answer):** Mitomycin-C (MMC) is a potent fibroblast inhibitor derived from *Streptomyces caespitosus*. In ENT, it is used topically (typically 0.4 mg/ml) to prevent the formation of excessive scar tissue. In **Laryngotracheal Stenosis (LTS)** and subglottic stenosis, it is applied following endoscopic dilation or laser excision. By inhibiting DNA synthesis and fibroblast proliferation, it reduces the deposition of collagen, thereby preventing restenosis and improving the long-term patency of the airway. **Analysis of Incorrect Options:** * **Sturge-Weber Syndrome:** This is a neurocutaneous disorder characterized by port-wine stains and leptomeningeal angiomas. Management involves laser therapy for skin lesions and anticonvulsants; MMC has no role here. * **Endoscopic Angiofibroma:** Juvenile Nasopharyngeal Angiofibroma (JNA) is a highly vascular tumor. The mainstay of treatment is preoperative embolization followed by surgical excision. MMC does not address the vascular nature of this tumor. * **Skull Base Osteomyelitis:** This is a severe infection (usually Pseudomonas) requiring long-term intravenous antibiotics and surgical debridement. MMC, an antiproliferative agent, is contraindicated in active infections as it may impair healing. **High-Yield Clinical Pearls for NEET-PG:** * **Other ENT uses of Mitomycin-C:** Prevention of synechiae after Functional Endoscopic Sinus Surgery (FESS), maintaining patency of choanal atresia repair, and preventing closure of a myringotomy (prolonging tube patency). * **Mechanism:** It acts as an alkylating agent that cross-links DNA. * **Application:** It is applied topically via a soaked cottonoid for approximately 2–5 minutes. * **LTS Grading:** Remember the **Cotton-Myer Classification** for grading the severity of subglottic stenosis based on the percentage of lumen reduction.

Question 149: In tracheostomy, the entry into the trachea is through which anatomical structures?

A. Cricoid cartilage
B. First tracheal ring
C. Second and third tracheal rings (Correct Answer)
D. Fourth and fifth tracheal rings

Explanation: In a standard elective tracheostomy, the goal is to create an airway that is safe, stable, and minimizes long-term complications. ### **Why Option C is Correct** The **second and third tracheal rings** (and occasionally the fourth) are the preferred sites for the tracheal incision. This location is considered the "ideal zone" because: 1. It is located below the cricoid cartilage, avoiding the risk of subglottic stenosis. 2. It provides easy access as the thyroid isthmus (which usually overlies the 2nd to 4th rings) can be easily retracted or divided. 3. It is high enough to avoid the innominate artery and the pleura, which are risks in lower dissections. ### **Why Other Options are Incorrect** * **Option A (Cricoid cartilage):** Entering through the cricoid is strictly contraindicated. Damage to the cricoid leads to **perichondritis** and subsequent **subglottic stenosis**, which is extremely difficult to treat. * **Option B (First tracheal ring):** The first ring is avoided to prevent trauma to the cricoid cartilage and to reduce the risk of post-operative laryngeal stenosis. * **Option D (Fourth and fifth tracheal rings):** While sometimes used in patients with long necks, entering too low increases the risk of damaging the **innominate artery** (leading to tracheoinnominate fistula) and increases the difficulty of the procedure due to the increasing depth of the trachea as it enters the thorax. ### **High-Yield Clinical Pearls for NEET-PG** * **Emergency Airway:** If an immediate airway is needed and a tracheostomy is too slow, a **Cricothyroidotomy** (through the cricothyroid membrane) is the procedure of choice. * **Thyroid Isthmus:** During tracheostomy, the isthmus is either retracted superiorly or divided and sutured. * **Bjork Flap:** An inferiorly based flap of the 2nd or 3rd tracheal ring sometimes sutured to the skin to create a permanent stoma. * **Most common early complication:** Hemorrhage. * **Most common late complication:** Tracheal stenosis.

Question 150: Laryngocele arises as a herniation of laryngeal mucosa through which membrane?

A. Thyrohyoid (Correct Answer)
B. Cricothyroid
C. Cricotracheal
D. Crisosternal

Explanation: ### Explanation **1. Why Thyrohyoid is Correct:** A laryngocele is an abnormal cystic expansion of the **saccule of the laryngeal ventricle**. The saccule is a blind pouch located between the vestibular folds (false cords) and the inner surface of the thyroid cartilage. When the saccule becomes filled with air and distends, it can remain within the larynx (**internal laryngocele**) or herniate outward. In an **external laryngocele**, the air-filled sac protrudes through the **thyrohyoid membrane**, specifically at the point where the **superior laryngeal artery and internal laryngeal nerve** pierce the membrane. This is the point of least resistance, allowing the sac to present as a compressible swelling in the neck. **2. Why Other Options are Incorrect:** * **Cricothyroid Membrane:** This membrane connects the cricoid and thyroid cartilages. It is the site for emergency cricothyroidotomy but is not the anatomical pathway for saccular herniation. * **Cricotracheal Membrane:** This connects the cricoid cartilage to the first tracheal ring. Herniation here is not associated with laryngeal saccules. * **Crisosternal (Sternocostal):** This refers to the junction between the ribs and the sternum; it is anatomically unrelated to the larynx. **3. High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Often seen in individuals with increased endolaryngeal pressure (e.g., **trumpet players, glass blowers**, or chronic coughers). * **Clinical Feature:** A "Bryce’s Sign" may be positive (gurgling sound on compressing the neck swelling). * **Diagnosis:** CT scan is the gold standard (shows an air-filled sac). * **Important Association:** In adults, a laryngocele may be secondary to a **squamous cell carcinoma** obstructing the ventricular orifice; direct laryngoscopy is mandatory to rule out malignancy. * **Laryngopyocele:** If the laryngocele becomes infected, it is termed a laryngopyocele.

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

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Laryngomalacia

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Epiglottitis

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Voice Disorders

Practice Questions

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