Diseases of the Larynx Practice Questions

Q: What is the initial management for a newborn presenting with stridor attributed to laryngomalacia?

Observation and supportive care. ### Explanation **Laryngomalacia** is the most common congenital anomaly of the larynx and the leading cause of congenital stridor in infants. It is characterized by the collapse of supraglottic structures (epiglottis, arytenoids) into the airway during inspiration. **Why Option A is Correct:** The vast majority (over 90%) of laryngomalacia cases are **mild to moderate** and self-limiting. The stridor typically appears at 2 weeks of age, peaks at 6–9 months, and resolves spontaneously by 18–24 months as the laryngeal cartilage matures and the airway widens. Therefore, the initial management is **observation, parental reassurance, and supportive care** (such as upright positioning during feeding). **Why Other Options are Incorrect:** * **Option B:** Urgent surgery is reserved only for "Severe Laryngomalacia" (approx. 10% of cases) presenting with cyanosis, apnea, failure to thrive, or cor pulmonale. * **Option C:** Corticosteroids are not the primary treatment for laryngomalacia; they are more relevant in inflammatory conditions like croup or subglottic hemangioma. However, treating comorbid **Gastroesophageal Reflux (GERD)** with PPIs is often necessary as reflux exacerbates laryngeal edema. * **Option D:** If surgery (Supraglottoplasty) is required, it is performed when symptoms are severe, regardless of age. Waiting until age two is counterintuitive, as the condition usually resolves naturally by then. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** Inspiratory stridor that **worsens** when the infant is supine, crying, or feeding, and **improves** when prone. * **Diagnostic Finding:** Flexible laryngoscopy shows "Omega-shaped" epiglottis and short aryepiglottic folds. * **Associated Condition:** GERD is present in up to 80% of these patients and must be managed to improve outcomes.

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

Epiglottis. **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).

Q: A 10-month-old child presents with an abnormal inspiratory sound. The mother complains that the sound increases with crying and decreases when the child sleeps in a prone position. What is the probable diagnosis?

Laryngomalacia. **Explanation:** The clinical presentation is classic for **Laryngomalacia**, the most common cause of congenital stridor. It is characterized by an inward collapse of supraglottic structures (like the epiglottis and arytenoids) during inspiration due to delayed laryngeal cartilage maturation. **Why Laryngomalacia is correct:** * **Inspiratory Stridor:** The hallmark sign, usually appearing within the first few weeks of life. * **Positional Variation:** Stridor **improves in the prone position** because gravity pulls the tongue and supraglottic structures forward, opening the airway. It worsens in the supine position, during feeding, or when the child is agitated/crying. * **Age:** It typically presents in infancy (peak at 6 months) and resolves spontaneously by 18–24 months. **Why other options are incorrect:** * **Croup (Laryngotracheobronchitis):** Presents with a "barking" cough, hoarseness, and fever. It is an acute viral infection, not a chronic positional sound. * **Acute Epiglottitis:** A medical emergency characterized by high fever, drooling, and a "tripod position." It has a rapid onset and the child appears toxic. * **Laryngitis:** Usually presents with hoarseness and throat pain in older children/adults, often following a viral upper respiratory infection. **NEET-PG High-Yield Pearls:** * **Diagnosis:** Definitive diagnosis is made via **Flexible Fiberoptic Laryngoscopy**, showing "Omega-shaped" epiglottis and collapse of aryepiglottic folds. * **Management:** Mostly conservative (observation) as 90% resolve spontaneously. Severe cases with failure to thrive or cyanosis require **Supraglottoplasty**. * **Key Differentiator:** If the stridor were **expiratory**, think of Tracheomalacia. If **biphasic**, think of Subglottic Stenosis.

Q: Bovine cough is characteristic of which condition?

Laryngeal granuloma. **Explanation:** **Bovine cough** is a characteristic clinical sign described as a hollow, non-explosive cough that lacks the normal "explosive" quality of a healthy cough. This occurs due to the **inability to close the glottis** effectively, preventing the buildup of subglottic pressure required for a forceful cough. 1. **Why Laryngeal Granuloma is correct:** A laryngeal granuloma (often post-intubation or due to vocal cord trauma) acts as a mechanical obstruction or prevents proper apposition of the vocal cords. When the vocal folds cannot meet in the midline to seal the airway, the patient cannot generate the sudden release of pressure, resulting in the "mooing" or bovine sound. This sign is also classically associated with **Recurrent Laryngeal Nerve (RLN) palsy**, where vocal cord paralysis leads to an incompetent glottis. 2. **Analysis of Incorrect Options:** * **Acute Epiglottitis:** Characterized by a "muffled" or **"hot potato voice"** and severe inspiratory stridor, but not a bovine cough. Patients typically present with the "4 Ds": Drooling, Dyspnea, Dysphonia, and Dysphagia. * **Tracheitis:** Bacterial tracheitis usually presents with a "brassy" or **croup-like barking cough**, high fever, and toxicity. **High-Yield Clinical Pearls for NEET-PG:** * **Bovine Cough:** Think RLN palsy (e.g., Pancoast tumor, aortic aneurysm) or mechanical glottic incompetence (Laryngeal granuloma). * **Barking/Brassy Cough:** Characteristic of Croup (Laryngotracheobronchitis). * **Whooping Cough:** Paroxysmal cough followed by a high-pitched inspiratory "whoop" (Pertussis). * **Staccato Cough:** Associated with *Chlamydia trachomatis* pneumonia in infants.

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

Radiation. **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%).

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

There is asymmetrical swelling of the vocal cords. **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.

Q: A 7-month-old infant presents with stridor since the tenth day of life. What is the most likely cause?

Laryngomalacia. **Explanation:** **Laryngomalacia** is the most common cause of congenital stridor and the most common congenital anomaly of the larynx. It is characterized by an inward collapse of the supraglottic structures (epiglottis, arytenoids) during inspiration due to neuromuscular immaturity or structural flaccidity. * **Clinical Presentation:** Stridor typically appears within the first **2 weeks of life**. It is characteristically **inspiratory**, high-pitched, and worsens when the infant is supine, crying, or feeding, but improves when the infant is prone. * **Diagnosis:** Confirmed by flexible fiberoptic laryngoscopy showing "omega-shaped" epiglottis and short aryepiglottic folds. **Analysis of Incorrect Options:** * **Laryngotracheobronchitis (Croup):** This is an acute viral infection typically seen in older infants (6 months to 3 years). It presents with a sudden onset of barking cough and fever, not a chronic stridor starting from the first weeks of life. * **Tracheoesophageal Fistula (TEF):** This presents primarily with feeding difficulties, choking, cyanosis, and aspiration pneumonia immediately after birth, rather than isolated stridor. * **Eventration of the Diaphragm:** This is a respiratory distress issue caused by the elevation of the diaphragm into the thorax. It presents with tachypnea and decreased breath sounds, not laryngeal stridor. **High-Yield Clinical Pearls for NEET-PG:** * **Management:** 90% of cases resolve spontaneously by 18–24 months. Surgical intervention (**Supraglottoplasty**) is reserved for severe cases with failure to thrive or cor pulmonale. * **Key Sign:** Inspiratory stridor that improves in the **prone position**. * **Associated Condition:** Gastroesophageal reflux (GERD) is frequently associated and can worsen the symptoms.

Q: What is the advantage of tracheostomy, listed EXCEPT for one option?

Increases dead space. **Explanation:** Tracheostomy is a life-saving procedure that involves creating an opening in the anterior wall of the trachea. The primary physiological advantage of a tracheostomy is that it **decreases anatomical dead space by approximately 30% to 50%**. By bypassing the upper respiratory tract (nose, pharynx, and larynx), the distance air must travel to reach the alveoli is shortened, which reduces the work of breathing and improves alveolar ventilation. Therefore, **Option D** is the correct answer as it incorrectly states that tracheostomy increases dead space. **Analysis of other options:** * **Option A (Facilitates bronchial toilet):** Tracheostomy allows direct access to the lower airways for frequent suctioning of secretions, which is crucial in patients with a poor cough reflex or chronic lung disease. * **Option B (Decreases dead space):** As explained above, this is a major physiological benefit, making it easier for patients with respiratory compromise to ventilate effectively. * **Option C (Facilitates pharyngeal secretion toilet):** By providing a secure airway and often utilizing a cuffed tube, tracheostomy prevents the aspiration of pharyngeal secretions into the lungs and allows for easier management of the oropharynx. **High-Yield Clinical Pearls for NEET-PG:** * **Dead Space Reduction:** Tracheostomy reduces dead space by ~150 ml in adults. * **Indications:** Respiratory failure, upper airway obstruction (e.g., laryngeal edema, tumors), and protection of the tracheobronchial tree. * **Complications:** The most common immediate complication is **hemorrhage**; the most common late complication is **tracheal stenosis**. * **Safe Triangle of Jackson:** The anatomical area used for emergency tracheostomy to avoid major vessels.

Q: Stridor is caused by?

Obstruction of the airway above the level of the trachea. **Explanation:** Stridor is a high-pitched, noisy respiration caused by turbulent airflow through a partially obstructed airway. The correct answer is **D (Obstruction above the level of the trachea)** because, by clinical definition, stridor originates from the **larynx or the extrathoracic trachea**. **Why Option D is correct:** The term "stridor" specifically refers to sounds produced by narrowing in the supraglottis, glottis, subglottis, or the cervical (extrathoracic) trachea. Since the larynx sits above the thoracic trachea, any obstruction at or above this level results in stridor. **Analysis of Incorrect Options:** * **Option A:** Obstruction *below* the level of the larynx (specifically in the intrathoracic bronchi) typically produces **Wheezing**, which is a continuous, musical whistling sound heard during expiration. * **Option B & C:** While these are partially true (obstruction at or above the larynx does cause stridor), they are too restrictive. Stridor encompasses the entire upper airway from the oropharynx down to the extrathoracic trachea. Option D is the most comprehensive anatomical description. **High-Yield Clinical Pearls for NEET-PG:** * **Inspiratory Stridor:** Suggests a lesion **above the vocal cords** (Supraglottic). * **Biphasic Stridor:** Suggests a lesion at the **Glottis or Subglottis** (e.g., Laryngomalacia, Subglottic stenosis). * **Expiratory Stridor:** Suggests a lesion in the **Trachea or Bronchi** (e.g., Tracheomalacia). * **Stertor:** A "snoring" sound produced by obstruction in the **nasopharynx or oropharynx** (different from stridor). * **Laryngomalacia** is the most common congenital cause of inspiratory stridor in infants.

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

Tracheal stenosis. **Explanation:** **Mitomycin C (MMC)** is a potent chemotherapeutic agent derived from *Streptomyces caespitosus*. In ENT practice, it is used topically for its ability to inhibit fibroblast proliferation and protein synthesis, thereby preventing excessive scarring and fibrosis. **Why Tracheal Stenosis is Correct:** In the management of **Tracheal and Subglottic Stenosis**, MMC is applied topically (usually 0.4–1.0 mg/ml) following endoscopic dilation or laser excision. By inhibiting the migration and proliferation of fibroblasts, it prevents the formation of granulation tissue and restenosis, maintaining the patency of the airway. **Analysis of Incorrect Options:** * **Basal Cell Carcinoma (A):** The primary treatment is surgical excision (Mohs surgery) or radiotherapy. While topical 5-Fluorouracil or Imiquimod may be used for superficial types, MMC is not the standard of care. * **Skull Base Osteomyelitis (C):** This is a severe infection (often Malignant Otitis Externa). Treatment requires long-term systemic antibiotics (e.g., Ciprofloxacin) and surgical debridement, not anti-proliferative agents. * **Angiofibroma (D):** Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign but locally aggressive vascular tumor. The mainstay of treatment is surgical excision, often preceded by preoperative embolization. **High-Yield Clinical Pearls for NEET-PG:** * **Other ENT uses of MMC:** Prevention of synechiae after Functional Endoscopic Sinus Surgery (FESS), maintaining patency in Choanal Atresia repair, and Endoscopic Dacryocystorhinostomy (DCR). * **Ophthalmology use:** Widely used in Glaucoma filtering surgery (Trabeculectomy) to prevent bleb fibrosis. * **Mechanism:** It acts as an alkylating agent that cross-links DNA.

Question 1

What is the initial management for a newborn presenting with stridor attributed to laryngomalacia?

Accepted Answer

Observation and supportive care

Answer

Urgent surgical intervention

Answer

Corticosteroid therapy

Answer

Surgical correction after the age of two years

Question 2

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

Accepted Answer

Epiglottis

Answer

True vocal cord

Answer

Arytenoid cartilage

Answer

Thyroid cartilage

Question 3

A 10-month-old child presents with an abnormal inspiratory sound. The mother complains that the sound increases with crying and decreases when the child sleeps in a prone position. What is the probable diagnosis?

Accepted Answer

Laryngomalacia

Answer

Croup

Answer

Acute epiglottitis

Answer

Laryngitis

Question 4

Bovine cough is characteristic of which condition?

Accepted Answer

Laryngeal granuloma

Answer

Acute epiglottitis

Answer

Tracheitis

Answer

None of the above

Question 5

What is the primary treatment for Stage II laryngeal carcinoma?

Accepted Answer

Radiation

Answer

Surgery

Answer

Chemotherapy

Answer

Neoadjuvant chemotherapy followed by surgery

Question 6

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

Accepted Answer

There is asymmetrical swelling of the vocal cords

Answer

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

A 7-month-old infant presents with stridor since the tenth day of life. What is the most likely cause?

Accepted Answer

Laryngomalacia

Answer

Laryngotracheobronchitis

Answer

Tracheoesophageal fistula

Answer

Eventration of the diaphragm

Question 8

What is the advantage of tracheostomy, listed EXCEPT for one option?

Accepted Answer

Increases dead space

Answer

Facilitates bronchial toilet

Answer

Decreases dead space

Answer

Facilitates pharyngeal secretion toilet

Question 9

Stridor is caused by?

Accepted Answer

Obstruction of the airway above the level of the trachea

Answer

Obstruction of the airway below the level of the larynx

Answer

Obstruction of the airway at the level of the larynx

Answer

Obstruction of the airway above the level of the larynx

Question 10

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

Accepted Answer

Tracheal stenosis

Answer

Basal skull carcinoma

Answer

Skull base osteomyelitis

Answer

Angiofibroma

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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