Diseases of the Larynx Practice Questions

Q: Maintenance of airway during laryngectomy in a patient with carcinoma of the larynx is best done by which of the following?

Tracheostomy. **Explanation:** In the surgical management of carcinoma of the larynx (Total Laryngectomy), the primary goal is the complete removal of the larynx, which results in a permanent separation of the digestive and respiratory tracts. **Why Tracheostomy is the Correct Choice:** During a laryngectomy, the larynx is excised, and the distal trachea is brought out to the skin of the neck to create a **permanent end-stoma**. A tracheostomy (specifically, a "low" tracheostomy or a per-operative tracheal intubation through a stoma) is the only definitive way to maintain a secure airway once the upper airway (larynx) is removed. It ensures bypass of the surgical site, prevents aspiration of blood/secretions, and allows the surgeon to work unimpeded in the neck. **Why Other Options are Incorrect:** * **Laryngeal Mask Airway (LMA):** This is a supraglottic airway device that sits above the vocal cords. Since the larynx is being surgically removed, an LMA cannot maintain an airway and would obstruct the surgical field. * **Laryngeal Tube:** Similar to the LMA, this is a supraglottic device. It is contraindicated in laryngeal surgery as it occupies the space that needs to be dissected. * **Combitube:** This is a double-lumen emergency airway device usually inserted blindly. It is entirely inappropriate for elective major head and neck surgery where a secure, definitive airway is required. **Clinical Pearls for NEET-PG:** * **Total Laryngectomy** results in a **permanent tracheostome**; the patient becomes a "total neck breather." * In cases of laryngeal mass with impending airway obstruction, a **"high" tracheostomy** is avoided to prevent tumor seeding (stomal recurrence). * **Post-laryngectomy:** The patient can no longer perform the Valsalva maneuver effectively due to the loss of the glottic closure reflex.

Q: Which anatomical landmark is used to determine the level of tracheostomy?

Isthmus of the thyroid. **Explanation:** The **isthmus of the thyroid gland** is the primary anatomical landmark used to determine the level of a tracheostomy. In a standard elective tracheostomy, the isthmus typically overlies the second, third, and fourth tracheal rings. To access the trachea, the surgeon must either retract the isthmus superiorly/inferiorly or divide it between clamps to expose the underlying tracheal rings. * **Why Option B is correct:** The isthmus serves as the "gatekeeper" to the trachea. Its identification is crucial for surgical orientation. Once the isthmus is managed, the incision is usually made in the **2nd and 3rd or 3rd and 4th tracheal rings**. * **Why Option A is wrong:** The **Cricoid cartilage** is the landmark for a **Cricothyroidotomy** (emergency airway), not a tracheostomy. Performing a tracheostomy at or above the cricoid is contraindicated as it leads to subglottic stenosis. * **Why Options C & D are wrong:** While the 2nd and 3rd tracheal rings are the *site* where the tracheal window is created, they are not the *landmark* used to navigate the procedure. The thyroid isthmus must be identified first to safely reach these rings. **High-Yield Clinical Pearls for NEET-PG:** 1. **Level of Tracheostomy:** High (1st ring - avoided), Mid (2nd, 3rd, 4th rings - **Preferred**), Low (below 4th ring - avoided due to risk of injury to the innominate artery). 2. **Emergency Airway:** Cricothyroidotomy is the procedure of choice for immediate airway obstruction. 3. **Most common complication (Immediate):** Hemorrhage (from thyroid vessels or anterior jugular veins). 4. **Most common late complication:** Tracheal stenosis.

Q: Which of the following is NOT a common cause of stridor?

Atrophic laryngitis. **Explanation:** Stridor is a high-pitched, predominantly inspiratory sound produced by turbulent airflow through a partially obstructed upper airway (larynx or trachea). **Why Atrophic Laryngitis is the correct answer:** Atrophic laryngitis is a chronic condition characterized by the atrophy of the laryngeal mucosa and crust formation. While it causes hoarseness of voice and a dry cough, it **does not typically cause significant airway narrowing** or acute obstruction. Therefore, it is not a recognized cause of stridor. **Analysis of Incorrect Options:** * **Foreign body in larynx and trachea:** This is a common cause of **acute stridor** in toddlers. A lodged object creates mechanical obstruction, leading to sudden-onset respiratory distress and inspiratory or biphasic stridor. * **Laryngomalacia:** This is the **most common congenital cause** of stridor in infants. It occurs due to an inward collapse of supraglottic structures (like the epiglottis) during inspiration, resulting in a characteristic "crowing" sound that worsens when the infant is supine. * **Multiple papillomas of larynx:** Also known as Juvenile Recurrent Respiratory Papillomatosis (caused by HPV 6 and 11), these benign growths physically obstruct the glottic opening, leading to progressive hoarseness and stridor. **NEET-PG High-Yield Pearls:** * **Most common cause of inspiratory stridor in neonates:** Laryngomalacia. * **Most common cause of acute stridor (6 months – 3 years):** Laryngotracheobronchitis (Croup). * **Biphasic stridor** usually indicates a lesion at the **subglottic** or tracheal level. * **Expiratory stridor (wheeze)** usually indicates obstruction in the **lower airways** (bronchi).

Q: Laryngeal edema is a life-threatening situation seen in association with which of the following conditions?

Ludwig's angina. ### Explanation **Ludwig’s Angina** is a rapidly spreading, life-threatening cellulitis of the submandibular space (including sublingual and submaxillary spaces), usually of dental origin. The correct answer is **C** because the infection causes massive swelling of the floor of the mouth, pushing the tongue superiorly and posteriorly. This displacement, combined with the spread of edema to the epiglottis and supraglottic structures via the parapharyngeal space, leads to acute airway obstruction and **laryngeal edema**. **Analysis of Incorrect Options:** * **A. Cavernous Sinus Thrombosis:** This is a late complication of infections in the "danger area of the face." It presents with proptosis, chemosis, and cranial nerve palsies (III, IV, V1, V2, VI), but does not typically cause laryngeal edema. * **B. Infection of Pharyngeal Tonsils:** Acute tonsillitis or adenoiditis primarily causes odynophagia or nasal obstruction. While a peritonsillar abscess (Quinsy) can cause some trismus, it rarely leads to generalized laryngeal edema unless it spreads to the deep neck spaces. * **D. Cellulitis:** General skin cellulitis (unless specifically involving the submandibular space as in Ludwig's) does not involve the deep neck structures required to trigger laryngeal edema. **Clinical Pearls for NEET-PG:** * **Source:** 70-80% of Ludwig’s Angina cases arise from the **2nd and 3rd lower molars**. * **Clinical Sign:** "Woody" or "brawny" edema of the neck; the patient often presents with a "bull-neck" appearance and drooling. * **Management:** The priority is **airway maintenance** (often requiring tracheostomy if intubation fails). Antibiotics and surgical drainage are secondary. * **Key Space:** It is a **submandibular space** infection; it does not involve the subdiaphragmatic or retropharyngeal spaces primarily.

Q: Which of the following is NOT true regarding Reinke's edema?

There is asymmetrical swelling of the vocal cords.. **Reinke’s Edema** is a condition characterized by the accumulation of gelatinous fluid in the **subepithelial space (Reinke’s space)** of the vocal cords, located between the squamous epithelium and the vocal ligament. ### Why Option C is the Correct Answer (The False Statement) Reinke’s edema typically presents as **symmetrical, bilateral swelling** of the entire length of the membranous vocal cords. While the degree of swelling may vary slightly between sides, the hallmark of the disease is its diffuse, bilateral nature, often described as "baggy" or "polypoid" vocal cords. Therefore, stating that it is asymmetrical is incorrect. ### Analysis of Other Options * **Option A (Vocal Abuse):** This is **true**. The primary etiological factors are chronic irritation, most commonly due to **heavy smoking** and **vocal abuse** (voice strain). * **Option B (Subepithelial space):** This is **true**. Reinke’s space is a potential space with sparse lymphatic drainage, making it prone to fluid accumulation under chronic irritation. * **Option D (Vocal cord stripping):** This is **true**. While smoking cessation and voice therapy are initial steps, the definitive surgical treatment is **decortication** or "vocal cord stripping" (Micro-laryngeal surgery), where the epithelium is incised and the gelatinous fluid is aspirated/removed. ### NEET-PG High-Yield Pearls * **Clinical Presentation:** Characteristically seen in middle-aged women who smoke, presenting with a **low-pitched, "husky" voice**. * **Histopathology:** Shows edema, vascular congestion, and hyalinization of the stroma. * **Hirano’s Layers:** Reinke’s space corresponds to the **superficial layer of the lamina propria**. * **Management Tip:** Always rule out hypothyroidism, as it can present with similar vocal cord changes (Myxedema of the larynx).

Q: What is the most common cause of laryngeal stridor in a 60-year-old male?

Carcinoma of the larynx. **Explanation:** The correct answer is **Carcinoma of the larynx**. In an elderly male (60 years old), any new-onset laryngeal symptom—particularly stridor or persistent hoarseness—must be considered a malignancy until proven otherwise. Stridor indicates a significant narrowing of the airway (usually >50% obstruction). Squamous cell carcinoma is the most common laryngeal malignancy and typically presents in this age group, often associated with a history of smoking and alcohol consumption. **Analysis of Incorrect Options:** * **Nasopharyngeal Carcinoma:** While common in certain demographics, it typically presents with a neck mass (level II lymph nodes), nasal obstruction, or serous otitis media. It does not primarily cause laryngeal stridor unless there is massive inferior extension or cranial nerve palsy affecting the vocal cords. * **Acute Severe Asthma:** This presents with expiratory wheezing rather than inspiratory stridor. While it causes respiratory distress, the pathology is in the lower airways (bronchioles), not the larynx. * **Reinke’s Edema:** This involves fluid accumulation in the subepithelial space of the vocal cords. While it causes a "low-pitched, gravelly voice," it rarely progresses to the point of causing acute stridor unless the edema is massive and bilateral. **Clinical Pearls for NEET-PG:** * **Age-related Stridor:** In neonates, the most common cause is **Laryngomalacia**. In children, it is often **Croup (Laryngotracheobronchitis)** or foreign body aspiration. In elderly patients, **Malignancy** is the top differential. * **Stridor Types:** * *Inspiratory:* Supraglottic/Glottic lesion. * *Biphasic:* Subglottic lesion. * *Expiratory:* Tracheal/Bronchial lesion. * **Rule of Thumb:** Any patient with hoarseness for more than 3 weeks requires a mandatory indirect laryngoscopy (IDL) or fiberoptic laryngoscopy to rule out carcinoma.

Q: Cadaveric position of vocal cords is seen in which condition?

Bilateral recurrent and superior laryngeal nerve palsy. ### Explanation The position of the vocal cords is determined by the balance of intrinsic laryngeal muscles. The **cadaveric position** (neutral position) occurs when the vocal cords are approximately 3.5 mm from the midline, representing a state of total denervation. **1. Why Option A is Correct:** The vocal cords are controlled by two main nerves: the **Recurrent Laryngeal Nerve (RLN)**, which supplies all intrinsic muscles except the cricothyroid, and the **Superior Laryngeal Nerve (SLN)**, specifically its external branch, which supplies the cricothyroid (the primary tensor). * In **Bilateral RLN palsy**, the cords usually lie in the paramedian position because the cricothyroid muscles (supplied by the intact SLN) continue to adduct the cords. * When **both the RLN and SLN are paralyzed bilaterally**, the cricothyroid also loses function. This results in a total loss of muscle tone, causing the cords to fall into the **cadaveric position**. **2. Why Other Options are Incorrect:** * **Option B (Bilateral RLN palsy):** The cords are in the **paramedian position**. This is a surgical emergency as it causes severe airway obstruction (stridor), though the voice may remain relatively good. * **Option C & D (SLN palsy):** Isolated SLN palsy primarily affects the tension of the cords. It results in a wavy or "scalloped" appearance of the cord margin and a loss of high-pitched notes, but not a cadaveric position. **3. High-Yield Clinical Pearls for NEET-PG:** * **Median Position (0 mm):** Seen in phonation. * **Paramedian Position (1.5 mm):** Seen in isolated RLN palsy. * **Cadaveric Position (3.5 mm):** Seen in combined RLN + SLN palsy. * **Full Abduction (7 mm):** Seen during deep inspiration. * **Semon’s Law:** States that in progressive nerve lesions, the abductor fibers (posterior cricoarytenoid) are more susceptible and paralyzed earlier than adductor fibers.

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

Subglottic stenosis. **Explanation:** Tracheostomy complications are traditionally classified into immediate, intermediate, and late. Understanding the anatomical level of the procedure is key to identifying its complications. **Why Subglottic Stenosis is the Correct Answer:** Subglottic stenosis is typically a complication of **prolonged endotracheal intubation** or a **high tracheostomy** (where the incision involves the first tracheal ring or cricoid cartilage). In a standard tracheostomy, the incision is made between the 2nd and 4th tracheal rings. Since the subglottis (the area below the vocal cords and within the cricoid ring) is located **above** the standard tracheostomy site, a correctly performed procedure does not cause subglottic stenosis. Instead, the corresponding late complication of tracheostomy is **Tracheal Stenosis** (at the site of the stoma or cuff). **Analysis of Incorrect Options:** * **Surgical Emphysema:** An immediate complication caused by air escaping into the subcutaneous tissues, often due to tight skin suturing or excessive dissection of pretracheal fascia. * **Pneumothorax:** Occurs due to direct injury to the apical pleura (especially in children where the pleura is high) or due to air tracking through the mediastinum (pneumomediastinum) into the pleural space. * **Carotid Artery Injury:** Though rare, the carotid artery or the innominate artery can be injured during the procedure, especially in cases of aberrant anatomy or "low" tracheostomies. **High-Yield Clinical Pearls for NEET-PG:** * **Most common immediate complication:** Hemorrhage. * **Most common late complication:** Tracheal stenosis. * **Most common cause of death in tracheostomy:** Displacement of the tube or accidental decannulation. * **Tracheoinnominate Artery Fistula:** A rare but fatal late complication usually occurring due to a low-placed stoma (below the 4th ring).

Question 1

An end tracheostomy is performed in patients undergoing which of the following procedures?

Accepted Answer

Laryngectomy

Answer

Laryngofissure surgery

Answer

Oropharyngeal tumor resection

Answer

Surgical correction of obstructive sleep apnea with stridor

Question 2

Maintenance of airway during laryngectomy in a patient with carcinoma of the larynx is best done by which of the following?

Accepted Answer

Tracheostomy

Answer

Laryngeal mask airway

Answer

Laryngeal tube

Answer

Combitube

Question 3

Which anatomical landmark is used to determine the level of tracheostomy?

Accepted Answer

Isthmus of the thyroid

Answer

Cricoid cartilage

Answer

Second tracheal ring

Answer

Third tracheal ring

Question 4

Which of the following is NOT a common cause of stridor?

Accepted Answer

Atrophic laryngitis

Answer

Foreign body in larynx and trachea

Answer

Laryngomalacia

Answer

Multiple papillomas of larynx

Question 5

Laryngeal edema is a life-threatening situation seen in association with which of the following conditions?

Accepted Answer

Ludwig's angina

Answer

Cavernous sinus thrombosis

Answer

Infection of pharyngeal tonsils

Answer

Cellulitis

Question 6

Which of the following is NOT true regarding Reinke's edema?

Accepted Answer

There is asymmetrical swelling of the vocal cords.

Answer

It is usually caused by vocal abuse.

Answer

There is a collection of edema fluid in the subepithelial space.

Answer

Vocal cord stripping is the treatment.

Question 7

What is the most common cause of laryngeal stridor in a 60-year-old male?

Accepted Answer

Carcinoma of the larynx

Answer

Nasopharyngeal carcinoma

Answer

Acute severe asthma

Answer

Reinke's edema

Question 8

Cadaveric position of vocal cords is seen in which condition?

Accepted Answer

Bilateral recurrent and superior laryngeal nerve palsy

Answer

Bilateral recurrent laryngeal nerve palsy

Answer

Unilateral superior laryngeal nerve palsy

Answer

Bilateral superior laryngeal nerve palsy

Question 9

Which of the following are indications for tracheostomy?

Accepted Answer

Flail chest, Head injury, Tetanus, Foreign body

Answer

Head injury, Tetanus, Cardiac tamponade, Foreign body

Answer

Flail chest, Head injury, Tetanus, Cardiac tamponade

Answer

Flail chest, Head injury, Cardiac tamponade, Foreign body

Question 10

Which of the following is NOT a complication of tracheostomy?

Accepted Answer

Subglottic stenosis

Answer

Surgical emphysema

Answer

Pneumothorax

Answer

Carotid artery injury

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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