Diseases of the Larynx — MCQs

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 161: Which of the following is NOT a complication of tracheostomy?

A. Surgical emphysema
B. Pneumothorax
C. Carotid artery injury
D. Subglottic stenosis (Correct Answer)

Explanation: **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 162: What is the most common site in the larynx for sarcoidosis?

A. Epiglottis (Correct Answer)
B. Vocal cord
C. Cartilage
D. None of the above

Explanation: **Explanation:** Laryngeal sarcoidosis is a rare manifestation of systemic sarcoidosis, occurring in approximately 1–5% of cases. It is characterized by the formation of non-caseating granulomas in the laryngeal tissues. **Why Epiglottis is the Correct Answer:** The disease has a strong predilection for the **supraglottic larynx** because of its rich lymphatic network. Within the supraglottis, the **epiglottis** is the most frequently involved site. On examination, it typically appears thickened, pale, and edematous (often described as "turban-shaped"), which can lead to symptoms like globus sensation, dysphagia, or airway obstruction. **Analysis of Incorrect Options:** * **Vocal Cords (Glottis):** Involvement of the true vocal cords is extremely rare. Sarcoidosis primarily affects the "loose" mucosa of the supraglottis rather than the tightly bound squamous epithelium of the vocal folds. * **Cartilage:** While sarcoidosis can affect various connective tissues, it is primarily a mucosal and submucosal disease in the larynx. It does not typically originate in or primarily target the laryngeal cartilages. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Epiglottis (Supraglottis). * **Classic Appearance:** Pale, edematous, "turban-like" epiglottis. * **Presenting Symptom:** Most patients are asymptomatic, but the most common symptom is hoarseness or inspiratory stridor if the airway is narrowed. * **Diagnosis:** Definitive diagnosis requires a biopsy showing **non-caseating granulomas** and exclusion of other causes like tuberculosis (which usually involves the posterior larynx). * **Treatment:** Systemic or intralesional corticosteroids are the mainstay of management.

Question 163: Which of the following conditions is associated with laryngeal nerve paralysis?

A. Multinodular goitre
B. Graves' disease
C. Riedel's thyroiditis
D. Anaplastic thyroid cancer (Correct Answer)

Explanation: **Explanation:** The correct answer is **Anaplastic thyroid cancer**. **1. Why Anaplastic Thyroid Cancer is correct:** The Recurrent Laryngeal Nerve (RLN) runs in the tracheoesophageal groove, in close proximity to the thyroid gland. In cases of **malignant** thyroid tumors, especially aggressive types like Anaplastic carcinoma, the tumor frequently breaches the thyroid capsule and **infiltrates** surrounding structures. Paralysis of the vocal cords occurs due to direct neoplastic invasion or compression of the RLN. In clinical practice, a thyroid mass associated with hoarseness of voice (vocal cord palsy) is a hallmark sign of malignancy. **2. Why the other options are incorrect:** * **Multinodular Goitre (MNG):** This is a benign condition. While the gland can become very large (retrosternal goitre), it rarely causes nerve paralysis because it tends to displace the nerve rather than invade it. * **Graves' Disease:** This is an autoimmune hyperthyroid state characterized by diffuse hyperplasia. It does not involve invasive growth or nerve destruction. * **Riedel’s Thyroiditis:** Although this involves dense fibrosis that can mimic malignancy by "fixing" the thyroid to local structures, RLN paralysis is extremely rare compared to the invasive nature of Anaplastic cancer. **3. NEET-PG High-Yield Pearls:** * **Most common cause of unilateral RLN palsy:** Thyroid surgery (iatrogenic trauma). * **Most common thyroid malignancy causing RLN palsy:** Anaplastic carcinoma (due to its rapid, aggressive local invasion). * **Semon’s Law:** In progressive lesions of the RLN, the abductor fibers (Posterior Cricoarytenoid) are more susceptible and paralyzed before the adductor fibers. * **Position of Cord:** In complete RLN paralysis, the vocal cord usually assumes a **paramedian position**.

Question 164: What is the gold standard treatment for intractable aspiration in a patient with an incompetent larynx due to complete laryngeal paralysis?

A. Type I Thyroplasty
B. Tracheostomy
C. Feeding jejunostomy
D. Tracheal division and permanent tracheostoma (Correct Answer)

Explanation: **Explanation:** The management of **intractable aspiration** focuses on separating the air passage from the food passage to prevent life-threatening aspiration pneumonia. **1. Why Option D is Correct:** **Tracheal division (Laryngotracheal separation)** with a permanent tracheostoma is considered the **gold standard** for intractable aspiration. In this procedure, the trachea is transected; the proximal end (leading to the larynx) is sewn shut, and the distal end is brought out as a permanent stoma. This creates a definitive physical barrier, ensuring that no secretions or food can enter the lungs, even if the larynx is completely incompetent. **2. Why Other Options are Incorrect:** * **Type I Thyroplasty (Option A):** This is a medialization procedure used for unilateral vocal cord palsy to improve voice and mild aspiration. It is insufficient for "intractable" aspiration where the entire laryngeal protective mechanism has failed. * **Tracheostomy (Option B):** While it provides an airway and allows for suctioning, a standard tracheostomy (even with a cuffed tube) does not prevent aspiration. In fact, it can sometimes worsen aspiration by tethering the larynx. * **Feeding Jejunostomy (Option C):** This addresses nutrition but does not stop the aspiration of oropharyngeal secretions (saliva), which is often the primary cause of pneumonia in these patients. **3. High-Yield Clinical Pearls for NEET-PG:** * **Intractable Aspiration:** Usually seen in bilateral laryngeal paralysis, advanced bulbar palsy, or post-extensive head and neck surgery. * **Narrow Field Laryngectomy:** Another definitive surgical option for aspiration, but more morbid than tracheal division. * **Epiglottopexy:** A surgical technique to close the laryngeal inlet, but it has a higher failure rate compared to tracheal division. * **Key Goal:** In intractable cases, the priority shifts from "voice preservation" to "pulmonary protection."

Question 165: Which of the following is FALSE regarding unilateral Recurrent Laryngeal Nerve palsy?

A. Has normal speech
B. No risk of aspiration
C. Difficulty in breathing (Correct Answer)
D. Conservative management

Explanation: In unilateral Recurrent Laryngeal Nerve (RLN) palsy, the affected vocal cord typically assumes a **paramedian position**. This occurs because the cricothyroid muscle (innervated by the Superior Laryngeal Nerve) remains intact and acts as an adductor. ### Why "Difficulty in Breathing" is the Correct (False) Statement: In unilateral palsy, the contralateral vocal cord is fully mobile and can abduct normally. This provides a **sufficient glottic airway** for quiet respiration and even moderate exertion. Therefore, patients do **not** experience dyspnea or difficulty in breathing. Airway compromise only occurs in *bilateral* RLN palsy, where both cords meet in the midline, causing stridor. ### Explanation of Other Options: * **A. Has normal speech:** Initially, the patient may have a weak, breathy voice (hoarseness). However, over time, the healthy vocal cord compensates by crossing the midline to meet the paralyzed cord, often resulting in near-normal speech. * **B. No risk of aspiration:** Since the unaffected cord can still approximate the paralyzed one and the laryngeal sensations (internal branch of SLN) are intact, the protective cough reflex and glottic closure are usually sufficient to prevent aspiration. * **D. Conservative management:** Most cases of unilateral RLN palsy are managed conservatively with **speech therapy** for 6–12 months, as many recover spontaneously or compensate well. Surgical intervention (e.g., medialization thyroplasty) is only considered if compensation fails. ### High-Yield Clinical Pearls for NEET-PG: * **Most common cause:** Surgical trauma (Thyroidectomy) is the most common overall, but idiopathic/viral is also frequent. * **Left vs. Right:** Left RLN palsy is more common due to its longer intrathoracic course (related to the arch of the aorta). * **Semon’s Law:** In progressive lesions, abductor fibers are injured first; thus, the cord initially moves to the midline. * **Position of cord:** In pure RLN palsy, the cord is **paramedian**; in combined RLN + SLN palsy (Total palsy), the cord is in the **cadaveric position** (midway between abduction and adduction).

Question 166: Which of the following structures are NOT removed in a vertical partial laryngectomy?

A. True vocal cord
B. Epiglottis (Correct Answer)
C. Arytenoid cartilage
D. Thyroid cartilage

Explanation: **Explanation:** **Vertical Partial Laryngectomy (VPL)**, also known as a **Hemilaryngectomy**, is a voice-conserving surgery indicated for T1 and select T2 glottic carcinomas. The fundamental principle of VPL is the removal of the affected side of the larynx along a vertical plane, specifically targeting the glottic region. **Why Epiglottis is the Correct Answer:** The **Epiglottis** is a supraglottic structure. Vertical partial laryngectomy is designed for glottic lesions (vocal cords). In a standard VPL, the resection remains below the level of the false vocal cords and does not involve the supraglottis. Therefore, the epiglottis is preserved to maintain airway protection during swallowing. **Analysis of Incorrect Options:** * **True Vocal Cord:** This is the primary structure removed. The surgery is performed for tumors involving one vocal cord. * **Thyroid Cartilage:** The overlying thyroid cartilage ala (on the affected side) is resected as part of the specimen to ensure adequate margins. * **Arytenoid Cartilage:** Depending on the posterior extent of the tumor, the vocal process or the entire arytenoid cartilage on the involved side may be removed to achieve oncological clearance. **NEET-PG High-Yield Pearls:** * **Horizontal Partial Laryngectomy:** Also known as Supraglottic Laryngectomy. It removes the epiglottis and false cords but **preserves** both true vocal cords. * **Prerequisite for VPL:** The contralateral vocal cord must be mobile and healthy. * **Voice Quality:** Post-VPL, the voice is "hoarse but functional" because the remaining cord vibrates against a scarred neo-glottis. * **Key Contraindication for VPL:** Extension of the tumor to the subglottis (>10mm) or fixed vocal cords (T3).

Question 167: The "thumb sign" on lateral neck X-ray is characteristic of which condition?

A. Acute epiglottitis (Correct Answer)
B. Acute Laryngotracheobronchitis (Croup)
C. Acute tonsillitis
D. Laryngitis

Explanation: ### Explanation **1. Why Acute Epiglottitis is correct:** Acute epiglottitis is a life-threatening inflammatory condition, most commonly caused by *Haemophilus influenzae* type B (HiB). On a **lateral neck X-ray**, the normally thin, leaf-like epiglottis becomes severely swollen and rounded due to edema. This enlarged silhouette resembles the distal phalanx of a human thumb, leading to the classic **"Thumb sign."** This swelling can rapidly progress to complete airway obstruction. **2. Why the other options are incorrect:** * **Acute Laryngotracheobronchitis (Croup):** This condition typically presents with subglottic narrowing. On an **Anteroposterior (AP) view** of the neck, this produces the **"Steeple sign"** (pencil-tip appearance), not the thumb sign. * **Acute Tonsillitis:** This involves inflammation of the palatine tonsils. While it causes throat pain and dysphagia, it does not typically present with the specific radiological thumb sign on a lateral neck film. * **Laryngitis:** This is generally a self-limiting inflammation of the vocal cords causing hoarseness. It does not produce the massive supraglottic swelling seen in epiglottitis. **3. Clinical Pearls for NEET-PG:** * **Clinical Triad:** Drooling, Dysphagia, and Distress (The 3 D's). * **Positioning:** Patients often assume the **"Tripod position"** (leaning forward with hands on knees) to maintain the airway. * **Management Gold Standard:** Secure the airway first (intubation or tracheostomy). **Never** examine the throat with a tongue depressor in a suspected case, as it may trigger fatal laryngospasm. * **Incidence:** Has significantly decreased due to the **HiB vaccine**.

Question 168: What is the primary treatment for Stage II laryngeal carcinoma?

A. Radiation (Correct Answer)
B. Surgery
C. Chemotherapy
D. Neoadjuvant chemotherapy followed by surgery

Explanation: **Explanation:** The management of laryngeal carcinoma is primarily determined by the stage of the disease and the goal of organ preservation. **Stage II laryngeal carcinoma** (T2N0M0) is considered early-stage disease. **Why Radiation is the Correct Answer:** For early-stage laryngeal cancer (Stages I and II), both **Radiotherapy (RT)** and **Conservative Surgery** (like Transoral Laser Microsurgery) offer comparable local control and survival rates. However, **Radiation Therapy** is traditionally preferred as the primary treatment because it offers superior **voice preservation** and functional outcomes compared to surgical interventions, which may alter the quality of the voice. **Analysis of Incorrect Options:** * **B. Surgery:** While partial laryngectomy is an option for Stage II, it is often reserved for patients who cannot undergo RT or as a salvage procedure. It carries a higher risk of morbidity regarding swallow and voice function. * **C. Chemotherapy:** Single-modality chemotherapy is not a curative treatment for laryngeal cancer. It is typically used as part of concurrent chemoradiation for advanced stages (Stage III and IV). * **D. Neoadjuvant Chemotherapy:** This is generally indicated in advanced, resectable tumors to assess chemosensitivity or to shrink tumors before definitive treatment, not for early-stage (Stage II) disease. **Clinical Pearls for NEET-PG:** * **Stage I & II:** Single modality treatment (RT or Surgery). RT is preferred for better voice quality. * **Stage III & IV:** Multimodality treatment. The standard is **Concurrent Chemoradiotherapy** (Organ preservation protocol). * **Total Laryngectomy:** Indicated for T4a (advanced disease with cartilage invasion) or as salvage for RT failure. * **Most common site:** Glottis (best prognosis due to early symptoms and sparse lymphatics). * **Most common histology:** Squamous Cell Carcinoma (>95%).

Question 169: All of the following are true regarding Reinke's edema except?

A. Usually caused by vocal abuse
B. There is a collection of edema fluid in the subepithelial space
C. There is asymmetrical swelling of the vocal cords (Correct Answer)
D. Vocal cord stripping is the treatment

Explanation: **Explanation:** Reinke’s edema (polypoid degeneration) is a condition characterized by the accumulation of gelatinous fluid in the **subepithelial space (Reinke’s space)** of the vocal cords. **1. Why Option C is the correct answer (The False Statement):** Reinke’s edema typically presents as **bilateral and symmetrical** swelling of the vocal cords. While the severity may vary slightly between sides, the hallmark of the disease is diffuse, fusiform swelling involving the entire length of both membranous vocal folds. Asymmetrical or unilateral swelling should raise suspicion for other pathologies like polyps or cysts. **2. Analysis of other options:** * **Option A (Vocal Abuse):** This is a true statement. The primary etiologies are chronic **vocal abuse** and **heavy smoking**. It is most commonly seen in middle-aged women who smoke ("Smoker’s dysphonia"). * **Option B (Subepithelial space):** This is true. Reinke’s space is a potential space between the squamous epithelium and the vocal ligament. It lacks lymphatic drainage, which leads to the accumulation of fluid under chronic irritation. * **Option C (Vocal cord stripping):** This is true. The definitive treatment is surgical. **Decortication or vocal cord stripping** (using a "microflap" technique) is performed to evacuate the gelatinous material. **High-Yield Clinical Pearls for NEET-PG:** * **Voice Quality:** Characteristically low-pitched, "husky," or "man-like" voice in females. * **Stroboscopy:** Shows increased mucosal wave and amplitude due to the loose fluid. * **Management:** Smoking cessation is mandatory to prevent recurrence. Surgery is reserved for significant airway obstruction or persistent dysphonia. * **Histology:** Shows edema, vascular congestion, and occasional fibrin deposition in the superficial lamina propria.

Question 170: Omega shaped epiglottis is seen in which of the following conditions?

A. Laryngomalacia (Correct Answer)
B. Epiglottitis
C. Tuberculosis
D. Carcinoma of the epiglottis

Explanation: **Explanation:** **Laryngomalacia** is the most common congenital anomaly of the larynx and the leading cause of congenital stridor. It is characterized by an inward collapse of the supraglottic structures during inspiration due to excessive flaccidity of the laryngeal tissues. The classic endoscopic finding is an **"Omega-shaped" (Ω) epiglottis**, caused by the lateral folds of the epiglottis curling inwards. This is often accompanied by short aryepiglottic folds and bulky arytenoids that prolapse into the glottis. **Analysis of Incorrect Options:** * **Epiglottitis:** Characterized by a "cherry-red," swollen, and edematous epiglottis. On a lateral X-ray of the neck, it presents with the **"Thumb sign."** * **Tuberculosis of Larynx:** Typically presents with a **"mousetibbled"** appearance of the vocal cords or a **"turban-shaped"** epiglottis due to pseudo-edematous infiltration. * **Carcinoma of the Epiglottis:** Usually presents as an exophytic, fungating mass or an ulcerative lesion, leading to structural destruction rather than a specific geometric shape like an Omega. **Clinical Pearls for NEET-PG:** * **Stridor:** In laryngomalacia, the stridor is **inspiratory**, increases with crying or feeding, and improves when the child is placed in the **prone position**. * **Diagnosis:** Flexible fiberoptic laryngoscopy is the gold standard (shows inspiratory collapse). * **Management:** Most cases (90%) resolve spontaneously by age 2. Severe cases (with failure to thrive or cyanosis) require **supraglottoplasty**. * **Radiology:** On X-ray, the "Omega shape" is not visible; it is a direct visualization finding.

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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