Diseases of the Larynx Practice Questions

Q: Which part of the larynx shows the highest lymph node involvement in carcinoma?

Supraglottic carcinoma. ### 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%).

Q: Which of the following statements about epiglottitis is TRUE?

It is seen in elderly individuals using crack cocaine.. **Explanation:** **Epiglottitis** (Supraglottitis) is a life-threatening inflammatory condition of the epiglottis and surrounding structures. **Why Option B is Correct:** While traditionally a pediatric disease, the epidemiology has shifted due to the Hib vaccine. In adults, epiglottitis is increasingly recognized in specific risk groups. **Thermal injury** to the supraglottic airway from inhaling heated vapors, such as those produced during **crack cocaine** smoking or marijuana use, can cause rapid-onset edema and inflammation mimicking infectious epiglottitis. **Analysis of Incorrect Options:** * **Option A:** It is **not** more common in infants. The peak incidence in children used to be 2–5 years, but it is now more frequently seen in **adults** (mean age 40s) due to widespread *Haemophilus influenzae* type b (Hib) vaccination. * **Option C:** Blood cultures are positive in approximately **25–30% of adult cases** and about 50–70% of pediatric cases. They are "often" positive but certainly not "almost always" (which implies >90%). * **Option D:** The treatment of choice is **Ceftriaxone** (a 3rd generation cephalosporin) to cover beta-lactamase-producing *H. influenzae*. While Co-amoxiclav has activity, Ceftriaxone is the gold standard for empirical management in acute settings. **High-Yield Clinical Pearls for NEET-PG:** * **Causative Agent:** *H. influenzae* type b (most common), *Streptococcus pyogenes*, and *Staphylococcus aureus*. * **Classic Sign:** **Thumb sign** on lateral X-ray of the neck. * **Clinical Presentation:** The "4 Ds"—Drooling, Dysphagia, Dysphonia, and Distressed inspiratory efforts (Stridor). Patients often assume the **Tripod position**. * **Management:** The priority is **airway maintenance**. Do not examine the throat with a tongue depressor in children as it may trigger laryngospasm.

Q: What is true about Ackermans tumor?

It is verrucous carcinoma of the larynx. **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.

Q: Respiratory compromise is typically seen in which condition?

Bilateral recurrent laryngeal nerve palsy. **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).

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

Laryngotracheal stenosis. **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.

Q: In the Nodal "N" staging of laryngeal carcinoma, extranodal invasion is indicated by which category?

N3B. **Explanation:** The staging of laryngeal carcinoma follows the **AJCC 8th Edition** TNM classification. The 8th edition introduced a significant change by incorporating **Extranodal Extension (ENE)** into the "N" staging, as it is a major prognostic indicator for poor outcomes. **1. Why N3b is correct:** According to the AJCC 8th Edition, the **N3** category is subdivided based on size and ENE: * **N3a:** Metastasis in a lymph node larger than 6 cm in greatest dimension, but **without** extranodal extension (ENE-). * **N3b:** Metastasis in any node(s) with **clinically overt extranodal extension (ENE+)**. This means if ENE is present, the size or number of nodes no longer dictates the stage; it automatically becomes N3b. **2. Why other options are incorrect:** * **N2c:** Represents bilateral or contralateral lymph node metastasis, none larger than 6 cm, and without ENE. * **N3a:** As mentioned, this is a large node (>6 cm) but specifically lacks extranodal invasion. * **N3c:** This category does not exist in the current AJCC TNM staging for laryngeal cancer. **High-Yield Clinical Pearls for NEET-PG:** * **ENE Definition:** Extension of tumor through the lymph node capsule into the surrounding connective tissue. * **Clinical ENE:** Suggested by skin involvement, fixation to adjacent structures (muscles/vessels), or nerve invasion. * **TNM 7th vs 8th:** In the 7th edition, N3 was simply any node >6 cm. The 8th edition added ENE to refine prognostic accuracy. * **Most common site:** The most common site for laryngeal cancer is the **Glottis**, but **Supraglottic** cancers have a higher rate of nodal metastasis due to rich lymphatic drainage.

Q: What is true about multiple papillomatosis?

It is a premalignant condition.. **Explanation:** **Multiple Papillomatosis** (specifically Juvenile Laryngeal Papillomatosis) refers to the development of multiple benign squamous papillomas in the respiratory tract [1]. **1. Why Option C is Correct:** While individual papillomas are benign, multiple papillomatosis is considered a **premalignant condition**. Although the risk of spontaneous malignant transformation into squamous cell carcinoma is low (approx. 1–3%), it is a well-documented complication, especially in cases with long-standing disease or those exposed to co-carcinogens [1]. **2. Why the other options are incorrect:** * **Option A:** The causative agent is the **Human Papillomavirus (HPV)**, specifically genotypes **6 and 11**, not Herpes Simplex Virus. * **Option B:** **Radiotherapy is contraindicated.** It is not the treatment of choice because it significantly increases the risk of malignant transformation into an aggressive squamous cell carcinoma. The standard treatment is surgical debulking (CO2 laser or microdebrider). * **Option D:** Multiple papillomatosis is most common in **children (under age 5)** [1], often acquired during childbirth via an infected birth canal. A second peak occurs in adulthood (20–40 years), but the "multiple" juvenile form is classically a pediatric diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of symptoms:** Hoarseness of voice, chronic cough, and stridor. * **Histology:** Finger-like projections of non-keratinized stratified squamous epithelium with a central fibrovascular core and characteristic **koilocytic changes** [1]. * **Adjuvant therapy:** Cidofovir (antiviral) or Interferon-alpha may be used in refractory cases. * **Prevention:** The HPV vaccine (Gardasil) is effective in reducing the incidence of maternal transmission. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 745-746.

Q: A 65-year-old man presented with vocal cord palsy. He has a history of pan chewing since childhood. On examination, the abducting function of his vocal cord is impaired. Which nerve is most likely affected?

Recurrent laryngeal nerve. ### Explanation The correct answer is **Recurrent Laryngeal Nerve (RLN)**. **1. Why the Recurrent Laryngeal Nerve is correct:** The intrinsic muscles of the larynx are responsible for the abduction and adduction of the vocal cords. All intrinsic muscles of the larynx—except for the cricothyroid—are supplied by the **Recurrent Laryngeal Nerve**. Specifically, the **Posterior Cricoarytenoid (PCA)** is the sole abductor of the vocal cords (often called the "safety muscle of the larynx"). Therefore, any impairment in the abducting function of the vocal cord directly indicates a lesion or palsy of the RLN. **2. Why the other options are incorrect:** * **External Laryngeal Nerve:** This nerve supplies only the **Cricothyroid muscle**, which acts as a tensor of the vocal cords. Damage to this nerve leads to a loss of pitch and a "husky" voice, but not a loss of abduction. * **Mandibular Nerve:** This is a branch of the Trigeminal nerve (CN V) and supplies the muscles of mastication and sensory innervation to the lower face. It has no role in vocal cord movement. * **Vagus Nerve:** While the RLN is a branch of the Vagus nerve (CN X), a high vagal lesion would typically present with additional symptoms like dysphagia (due to pharyngeal branch involvement) or palatal palsy. The specific loss of abduction is the hallmark of its distal branch, the RLN. **3. High-Yield Clinical Pearls for NEET-PG:** * **Posterior Cricoarytenoid (PCA):** The only **abductor** (Safety muscle). * **Lateral Cricoarytenoid (LCA):** The primary **adductor**. * **Semon’s Law:** In progressive lesions of the RLN, abductor fibers are more susceptible and are paralyzed first compared to adductor fibers. * **Left RLN** is more commonly involved in vocal cord palsy because of its longer intrathoracic course (looping around the arch of the aorta), making it vulnerable to mediastinal pathologies (e.g., lung cancer, mitral stenosis/Ortner’s syndrome).

Question 1

Which part of the larynx shows the highest lymph node involvement in carcinoma?

Accepted Answer

Supraglottic carcinoma

Answer

Glottic carcinoma

Answer

Subglottic carcinoma

Answer

Equal incidence in all locations

Question 2

Which of the following statements about epiglottitis is TRUE?

Accepted Answer

It is seen in elderly individuals using crack cocaine.

Answer

It is more common in infants.

Answer

Blood culture is almost always positive.

Answer

Co-amoxiclav is the treatment of choice.

Question 3

What is true about Ackermans tumor?

Accepted Answer

It is verrucous carcinoma of the larynx

Answer

It is a highly malignant tumor

Answer

Radiotherapy is the treatment of choice

Answer

It spreads via lymphatics in the early stage

Question 4

Respiratory compromise is typically seen in which condition?

Accepted Answer

Bilateral recurrent laryngeal nerve palsy

Answer

Superior and recurrent laryngeal nerve palsy

Answer

Incomplete unilateral recurrent laryngeal nerve palsy

Answer

Complete unilateral recurrent laryngeal nerve palsy

Question 5

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

Accepted Answer

Laryngotracheal stenosis

Answer

Sturge-Weber syndrome

Answer

Endoscopic angiofibroma

Answer

Skull base osteomyelitis

Question 6

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

Accepted Answer

Second and third tracheal rings

Answer

Cricoid cartilage

Answer

First tracheal ring

Answer

Fourth and fifth tracheal rings

Question 7

Which of the following treatments is indicated for Juvenile Onset Recurrent Respiratory Papillomatosis?

Accepted Answer

Bevacizumab

Answer

Aerosol Cidofovir

Answer

Interferon Beta

Answer

Steroids

Question 8

In the Nodal "N" staging of laryngeal carcinoma, extranodal invasion is indicated by which category?

Accepted Answer

N3B

Answer

N2C

Answer

N3A

Answer

N3C

Question 9

What is true about multiple papillomatosis?

Accepted Answer

It is a premalignant condition.

Answer

Herpes Simplex Virus is the causative agent.

Answer

Radiotherapy is the treatment of choice.

Answer

It is more common in individuals aged 15 to 33 years.

Question 10

A 65-year-old man presented with vocal cord palsy. He has a history of pan chewing since childhood. On examination, the abducting function of his vocal cord is impaired. Which nerve is most likely affected?

Accepted Answer

Recurrent laryngeal nerve

Answer

External laryngeal nerve

Answer

Mandibular nerve

Answer

Vagus nerve

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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