Diseases of the Larynx — MCQs

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 171: What is the advantage of tracheostomy, listed EXCEPT for one option?

A. Facilitates bronchial toilet
B. Decreases dead space
C. Facilitates pharyngeal secretion toilet
D. Increases dead space (Correct Answer)

Explanation: **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.

Question 172: What is the gold standard surgical procedure for the prevention of chronic aspiration?

A. Thyroplasty
B. Tracheostomy
C. Tracheal diversion and permanent tracheostomy (Correct Answer)
D. Feeding gastrostomy

Explanation: **Explanation:** The management of chronic aspiration focuses on separating the air passage from the food passage to prevent life-threatening aspiration pneumonia. **Why Option C is Correct:** **Tracheal diversion (Lindeman procedure)** and its variant, the **Laryngotracheal separation**, are considered the **gold standard** for intractable aspiration. In these procedures, the trachea is divided; the upper segment is closed blindly or diverted into the esophagus, and the lower segment is brought out as a permanent end-tracheostomy. This creates a physical barrier that completely prevents pharyngeal secretions and food from entering the lower airway, while still allowing for potential reversibility in some cases. **Analysis of Incorrect Options:** * **A. Thyroplasty:** Specifically Type I (Medialization), this is used for vocal cord palsy to improve voice and mild aspiration. It does not provide the absolute protection required for chronic, severe aspiration. * **B. Tracheostomy:** While it provides airway access and allows for suctioning, a tracheostomy (even with a cuffed tube) **does not prevent aspiration**. In fact, it can worsen aspiration by tethering the larynx and reducing the cough reflex. * **D. Feeding Gastrostomy:** This addresses nutrition and prevents aspiration of *food* during swallowing, but it does nothing to prevent the aspiration of **saliva and oropharyngeal secretions**, which is a major cause of pneumonia in these patients. **High-Yield Clinical Pearls for NEET-PG:** * **Narrow-field Laryngectomy:** The most definitive (but irreversible) procedure for aspiration; it is usually reserved for patients with no hope of laryngeal function recovery. * **Epiglottopexy:** A surgical technique where the epiglottis is sutured to the aryepiglottic folds to "cap" the glottis. * **Key Indicator:** The primary goal in chronic aspiration is the **anatomical separation** of the respiratory and digestive tracts.

Question 173: Which one of the following laryngeal lesions is considered dangerous to life?

A. Bilateral adductor paralysis
B. Bilateral abductor paralysis (Correct Answer)
C. Combined nerve paralysis
D. Superior laryngeal nerve palsy

Explanation: **Explanation:** The correct answer is **Bilateral abductor paralysis**. **1. Why it is the correct answer:** In bilateral abductor paralysis, the **Posterior Cricoarytenoid (PCA)** muscles—the only abductors of the vocal cords—are paralyzed. This results in the vocal cords assuming a **median or paramedian position**. Because the cords cannot move outward (abduct) during inspiration, the glottic airway becomes severely narrowed. This leads to acute respiratory distress, inspiratory stridor, and potential asphyxia, making it a life-threatening emergency that often requires an immediate tracheostomy. **2. Why the other options are incorrect:** * **A. Bilateral adductor paralysis:** This is usually functional (hysterical) in nature. The cords remain in an abducted position; while the patient cannot phonate (aphonia), the airway remains wide open, posing no threat to life. * **C. Combined nerve paralysis:** This involves both the recurrent and superior laryngeal nerves. The cords typically lie in the **cadaveric position** (midway between median and lateral). While this causes a weak voice and risk of aspiration, the airway is usually adequate for breathing. * **D. Superior laryngeal nerve palsy:** This affects the cricothyroid muscle (the tensor of the cord). It results in a wavy cord margin and loss of pitch, but does not obstruct the airway. **Clinical Pearls for NEET-PG:** * **Most common cause:** Thyroid surgery (iatrogenic injury to bilateral recurrent laryngeal nerves). * **Semon’s Law:** States that in progressive nerve lesions, abductor fibers are more susceptible and perish before adductor fibers. * **Management:** Acute phase requires **tracheostomy**. Chronic cases may be managed by **Kashima’s procedure** (posterior cordectomy) or Woodman’s operation (arytenoidectomy) to widen the glottis.

Question 174: Which of the following anatomical structures is difficult to visualize or examine on indirect laryngoscopy?

A. True vocal cord
B. Anterior commissure (Correct Answer)
C. Epiglottis
D. False vocal cord

Explanation: **Explanation:** Indirect laryngoscopy (IDL) uses a plane mirror to visualize the larynx. While it provides a good overview of the laryngeal inlet, it has specific anatomical limitations due to the angle of reflection and the "overhanging" nature of certain structures. **Why the Anterior Commissure is the Correct Answer:** The **Anterior Commissure** is the junction where the two true vocal cords meet anteriorly. In many patients, this area is a **"blind spot"** during IDL because it is tucked deep under the base of the epiglottis. The curvature of the epiglottis often obscures the most anterior portion of the glottis, making it the most difficult area to visualize completely without using a flexible fiberoptic scope or direct laryngoscopy. **Analysis of Incorrect Options:** * **True Vocal Cords:** These are the primary structures visualized during IDL. They appear as pearly white bands and are easily seen abducted during inspiration and adducted during phonation. * **Epiglottis:** This is the first structure encountered during IDL. It serves as a landmark and is easily visible, though its shape (e.g., omega-shaped) can sometimes hide structures beneath it. * **False Vocal Cords (Ventricular Folds):** Located superior to the true cords, these mucosal folds are clearly visible lateral to the glottic opening. **High-Yield Clinical Pearls for NEET-PG:** * **Other Blind Spots in IDL:** Besides the anterior commissure, other difficult areas include the **ventricle of the larynx**, the **subglottis**, and the **apex of the pyriform fossa**. * **Killian’s Dehiscence:** A weak area between the thyropharyngeus and cricopharyngeus muscles, prone to Zenker’s diverticulum (often tested alongside laryngeal anatomy). * **Positioning:** To improve the view during IDL, the patient is asked to lean forward (sniffing position) and say "Hee" to pull the epiglottis anteriorly.

Question 175: Regarding Juvenile laryngeal papillomatosis, which of the following statements is false?

A. It is recurrent.
B. Interferon is used in its treatment.
C. It is premalignant.
D. HPV 18 is the causative agent. (Correct Answer)

Explanation: ### Explanation **Juvenile Laryngeal Papillomatosis (JLP)**, also known as Recurrent Respiratory Papillomatosis (RRP), is the most common benign neoplasm of the larynx in children. **1. Why Option D is the Correct (False) Statement:** The primary causative agents for JLP are **HPV types 6 and 11** [1]. These are "low-risk" genotypes. In contrast, **HPV 16 and 18** are "high-risk" genotypes associated with cervical cancer and oropharyngeal squamous cell carcinoma, but they are **not** the typical cause of juvenile laryngeal papillomas. **2. Analysis of Other Options:** * **Option A (Recurrent):** True. The hallmark of this disease is its aggressive tendency to recur after surgical excision, often requiring multiple procedures (hence the name "Recurrent Respiratory Papillomatosis") [2]. * **Option B (Interferon):** True. While CO2 laser excision or microdebrider excision is the gold standard, adjuvant therapies like **Interferon-alpha**, Cidofovir, and Indole-3-carbinol are used in severe, rapidly recurring cases to slow down the growth [1]. * **Option C (Premalignant):** True. Although rare (less than 1-3%), these benign lesions can undergo malignant transformation into squamous cell carcinoma, especially if there is a history of smoking or prior radiation therapy [2]. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mode of Transmission:** Usually occurs during childbirth via an infected birth canal (maternal HPV 6/11) [2]. * **Triad of Symptoms:** Hoarseness (most common), stridor, and dyspnea [2]. * **Most Common Site:** True vocal cords. * **Histopathology:** Shows finger-like projections of non-keratinized stratified squamous epithelium with a central vascular core. **Koilocytes** (vacuolated cells) are a characteristic finding. * **Management Goal:** To maintain a patent airway and preserve voice quality, not necessarily "cure," due to the high recurrence rate [2].

Question 176: A 26-year-old female presented with gradually increasing respiratory distress over 4 days. She has a history of hospitalization and mechanical ventilation with orotracheal intubation for 2 weeks. She is now diagnosed with severe tracheal stenosis. What would be the next line of management?

A. Laser excision and stent insertion
B. Steroids
C. Tracheal dilatation
D. Tracheal resection and end-to-end anastomosis (Correct Answer)

Explanation: **Explanation:** The patient presents with post-intubation tracheal stenosis, a common complication of prolonged mechanical ventilation. Pressure from the endotracheal tube cuff causes ischemic necrosis of the tracheal mucosa, leading to fibrosis and narrowing. **Why Option D is Correct:** **Tracheal resection and end-to-end anastomosis** is the **gold standard** and definitive treatment for severe or mature tracheal stenosis. In this case, the patient has "severe" stenosis following a significant period of intubation (2 weeks). Surgical resection of the stenotic segment with primary reconstruction offers the highest success rate and lowest recurrence compared to endoscopic methods. **Why Other Options are Incorrect:** * **Option A (Laser excision and stent insertion):** While used for short, web-like stenoses (<1 cm) or in patients unfit for surgery, it has a high rate of recurrence and granulation tissue formation. * **Option B (Steroids):** These may be used as an adjunct to reduce edema in the acute inflammatory phase but cannot reverse established, severe fibrotic stenosis. * **Option C (Tracheal dilatation):** This provides only temporary relief. It is often used as a palliative measure or a "bridge" to surgery, but it is not the definitive management for severe cases. **Clinical Pearls for NEET-PG:** * **Most common site:** The most common site of post-intubation stenosis is at the level of the **cuff** (due to pressure necrosis) or the **stoma** (if a tracheostomy was performed). * **Critical Diameter:** Symptoms of airway obstruction usually manifest when the tracheal lumen is reduced by more than **50%** (diameter <5-8 mm). * **Safe Resection Limit:** Up to **50% of the total tracheal length** (approx. 4-5 cm) can be safely resected and anastomosed primarily using laryngeal release maneuvers if necessary. * **Prevention:** Maintaining cuff pressure between **20-30 cm H₂O** is crucial to prevent ischemic injury.

Question 177: The laryngeal saccules are present in which anatomical space?

A. Paraglottic space
B. Pyriform fossa
C. Reinke's space
D. Laryngeal ventricles (Correct Answer)

Explanation: **Explanation:** The **laryngeal saccule** (also known as the appendix of the ventricle) is a blind pouch of mucous membrane that extends upward from the anterior part of the **laryngeal ventricle** (Sinus of Morgagni). It lies between the vestibular fold (false cord) and the inner surface of the thyroid cartilage. 1. **Why Option D is Correct:** The laryngeal ventricle is a fusiform recess between the vestibular and vocal folds. The saccule arises directly from this space. It contains numerous mucous glands that lubricate the vocal cords, often referred to as the **"Oil can of the larynx."** 2. **Why other options are incorrect:** * **Paraglottic space:** This is a potential space lateral to the laryngeal ventricles, bounded by the thyroid cartilage and the conus elasticus. While the saccule *projects into* this space, it is anatomically a derivative of the ventricle. * **Pyriform fossa:** This is a part of the **hypopharynx**, located lateral to the aryepiglottic folds. It is not part of the internal laryngeal cavity. * **Reinke’s space:** This is a potential subepithelial space in the vocal folds (between the epithelium and the vocal ligament). It is the site for Reinke’s edema, not the location of the saccules. **High-Yield Clinical Pearls for NEET-PG:** * **Laryngocele:** An abnormal cystic expansion of the saccule filled with air. It presents as a neck swelling that increases with the Valsalva maneuver. * **Saccular Cyst:** A fluid-filled (mucus) dilation of the saccule that does not communicate with the laryngeal lumen. * **Histology:** The saccule is lined by pseudostratified ciliated columnar epithelium.

Question 178: What is the most common cause of stridor in infants and young children?

A. Abductor palsy
B. Croup
C. Laryngomalacia (Correct Answer)
D. Epiglottitis

Explanation: **Explanation:** **Laryngomalacia** is the most common cause of congenital stridor and the overall most common cause of stridor in infants. It is characterized by an inward collapse of the supraglottic structures (epiglottis and aryepiglottic folds) during inspiration due to excessive flaccidity. * **Clinical Presentation:** It typically presents with **inspiratory stridor** that starts within the first few weeks of life. The stridor characteristically worsens when the infant is supine, crying, or feeding, and improves when prone. * **Diagnosis:** Flexible laryngoscopy is the gold standard, showing an **Omega-shaped epiglottis** and short aryepiglottic folds. **Why other options are incorrect:** * **Abductor Palsy:** This is the second most common cause of congenital stridor. It is often associated with neurological conditions like Arnold-Chiari malformation. * **Croup (Laryngotracheobronchitis):** While a very common cause of *acute* stridor in children (6 months to 3 years), it is an infectious etiology and not the most common cause overall across the infancy period. It presents with a "barking" cough and "steeple sign" on X-ray. * **Epiglottitis:** This is an acute, life-threatening emergency caused by *H. influenzae*. It presents with high fever, drooling, and a "thumb sign" on X-ray, but its incidence has significantly decreased due to the HiB vaccine. **High-Yield Clinical Pearls for NEET-PG:** * **Management:** Most cases of Laryngomalacia resolve spontaneously by 18–24 months. Surgery (**Supraglottoplasty**) is only indicated in severe cases with failure to thrive or cor pulmonale. * **Synchronous Airway Lesions:** Up to 15-20% of children with laryngomalacia may have a second airway lesion (e.g., subglottic stenosis).

Question 179: What is the most common indication for tracheostomy?

A. Laryngeal diphtheria
B. Foreign body aspiration (Correct Answer)
C. Carcinoma
D. Asthma

Explanation: **Explanation:** Tracheostomy is a surgical procedure that creates an opening in the anterior wall of the trachea to bypass an upper airway obstruction [1]. **Why Foreign Body Aspiration is Correct:** In the context of emergency clinical practice and competitive exams like NEET-PG, **Foreign Body (FB) aspiration** is considered the most common indication for an emergency tracheostomy [1]. When a foreign body becomes impacted in the larynx or subglottis, it causes acute, life-threatening airway obstruction. If the object cannot be removed via Heimlich maneuver or direct laryngoscopy, a tracheostomy is performed to establish a secure airway and prevent asphyxiation. **Analysis of Incorrect Options:** * **Laryngeal Diphtheria:** While a classic cause of airway obstruction (due to pseudomembrane formation), its incidence has drastically decreased due to widespread immunization (DPT/Pentavalent vaccine) [1]. * **Carcinoma:** Laryngeal or hypopharyngeal carcinoma is a common cause of *elective* or progressive airway obstruction, but it ranks below acute emergencies like foreign bodies in overall frequency for urgent intervention [1]. * **Asthma:** This is a disease of the lower airways (bronchospasm). Tracheostomy is ineffective because the obstruction is distal to the tracheal opening; management involves bronchodilators and steroids. **Clinical Pearls for NEET-PG:** * **Most common indication (Overall):** Respiratory failure requiring prolonged mechanical ventilation (to prevent subglottic stenosis from endotracheal tubes). * **Most common indication (Emergency):** Upper airway obstruction (e.g., Foreign body, trauma, or acute epiglottitis) [1]. * **Level of Tracheostomy:** Usually performed at the level of the **2nd and 3rd tracheal rings**. * **Most common immediate complication:** Hemorrhage. * **Most common late complication:** Tracheal stenosis.

Question 180: In direct laryngoscopy, which of the following structures cannot be visualized?

A. Cricothyroid membrane (Correct Answer)
B. Lingual surface of the epiglottis
C. Arytenoids
D. Pyriform fossa

Explanation: ### Explanation **1. Why the Correct Answer is Right:** Direct Laryngoscopy (DL) is a procedure used to visualize the interior of the larynx and the hypopharynx. During DL, the laryngoscope is passed through the mouth to provide a direct line of sight to the **endolaryngeal structures**. The **Cricothyroid membrane** is an **extralaryngeal** structure located on the external surface of the neck, between the thyroid and cricoid cartilages. Because it is part of the external framework and lies deep to the skin and prelaryngeal muscles, it cannot be seen from the mucosal/luminal side during laryngoscopy. It is typically accessed via the skin during emergency cricothyrotomy. **2. Analysis of Incorrect Options:** * **Lingual surface of the epiglottis:** This is the anterior surface of the epiglottis facing the tongue. It is easily visualized as the laryngoscope blade is advanced into the vallecula (Macintosh blade) or used to depress the epiglottis (Miller blade). * **Arytenoids:** These paired cartilages form the posterior boundary of the glottis. They are primary landmarks used to identify the laryngeal inlet during intubation and DL. * **Pyriform fossa:** These are mucosal recesses located on either side of the laryngeal inlet within the hypopharynx. They are routinely inspected during DL to rule out hidden malignancies or foreign bodies. **3. Clinical Pearls for NEET-PG:** * **Positioning:** For optimal visualization during DL, the "Sniffing Position" is used (Flexion of the lower cervical spine and Extension of the atlanto-occipital joint). * **Indications:** DL is used for biopsies, removal of foreign bodies, and assessing the extent of laryngeal tumors (T-staging). * **Blind Spots:** While DL provides a great view of the glottis, the **subglottis** and the **ventricle** are considered "difficult zones" to visualize completely without the aid of angled telescopes or fiberoptic endoscopes.

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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