Diseases of the Larynx Practice Questions

Q: What is the treatment of choice for a vocal nodule?

Microlaryngoscopic removal. **Explanation:** Vocal nodules (Singer’s or Teacher’s nodules) are benign, bilateral, symmetrical thickenings at the junction of the anterior 1/3rd and posterior 2/3rds of the vocal cords, caused by chronic vocal abuse. **Why Microlaryngoscopic (MLS) removal is correct:** While the initial management of vocal nodules is conservative (voice rest and speech therapy), **Microlaryngoscopic removal** is the definitive surgical treatment of choice for persistent or large nodules that do not respond to conservative measures. Using an operating microscope allows for precise excision while preserving the underlying *lamina propria*, which is essential for maintaining the mucosal wave and voice quality. **Analysis of Incorrect Options:** * **Radical excision:** This is contraindicated for benign lesions. It involves removing excessive tissue, which leads to scarring and permanent dysphonia. * **Cryotherapy:** This technique lacks precision. The extreme cold can cause unpredictable tissue damage and deep scarring of the vocal fold layers. * **Wait and watch:** While conservative management is the first step, "wait and watch" implies no intervention. In clinical practice, active speech therapy is required; if it fails, surgical intervention (MLS) is indicated. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Junction of anterior 1/3 and posterior 2/3 (point of maximum vibration). * **Demographics:** Most common in male children and adult females. * **Histopathology:** Early nodules are soft/edematous; chronic nodules are fibrotic/hyalinized. * **First-line treatment:** Always start with **Voice Therapy**. Surgery is reserved for refractory cases. * **Key Surgical Principle:** "Minimalist" surgery to avoid damaging the vocal ligament.

Q: Recurrent laryngeal nerve palsy produces vocal cord in which position?

Paramedian. ### Explanation The position of the vocal cords in nerve palsies is determined by the **Wagner and Grossman hypothesis**, which states that the cricothyroid muscle (supplied by the Superior Laryngeal Nerve) remains active even if the Recurrent Laryngeal Nerve (RLN) is paralyzed. **Why Paramedian is Correct:** In isolated **Recurrent Laryngeal Nerve (RLN) palsy**, all intrinsic muscles of the larynx are paralyzed except for the **cricothyroid**. The cricothyroid acts as a tensor and a weak adductor of the vocal cord. Its unopposed action pulls the vocal cord toward the midline, resulting in the **paramedian position** (1.5 mm from the midline). **Analysis of Incorrect Options:** * **Cadaveric (Option A):** This occurs in **Combined Palsy** (both RLN and SLN are paralyzed). Without the cricothyroid's adducting force, the cord falls further out into a neutral position (3.5 mm from the midline). * **Abducted (Option B):** This is the position during deep inspiration. It is not seen in RLN palsy because the Posterior Cricoarytenoid (the only abductor) is paralyzed. * **Adducted (Option C):** This is the position during phonation. While the cord is close to the midline in RLN palsy, it is specifically "paramedian" rather than fully adducted. **High-Yield Clinical Pearls for NEET-PG:** * **Semon’s Law:** In progressive lesions of the RLN, abductor fibers are injured first (more vulnerable), leading to an initial adducted position before reaching the paramedian state. * **Unilateral RLN Palsy:** Usually asymptomatic or presents with mild hoarseness as the healthy cord compensates. * **Bilateral RLN Palsy:** Presents with **Stridor** because both cords are in the paramedian position, severely narrowing the glottic airway. * **Most common cause of RLN palsy:** Thyroid surgery (iatrogenic injury).

Q: All of the following statements about recurrent laryngeal papillomatosis are true, except?

HPV6 is more virulent than HPV11.. ### **Explanation** **Recurrent Respiratory Papillomatosis (RRP)** is the most common benign neoplasm of the larynx in children, characterized by the growth of wart-like exophytic lesions. **1. Why Option C is the Correct Answer (The False Statement):** While both HPV 6 and 11 cause RRP, **HPV 11 is significantly more virulent** than HPV 6. Patients infected with HPV 11 tend to have a more aggressive clinical course, requiring more frequent surgical interventions, and are at a higher risk of airway obstruction and distal spread into the tracheobronchial tree. **2. Analysis of Other Options:** * **Option A:** RRP is indeed caused by the **Human Papilloma Virus (HPV)**, a double-stranded DNA virus. * **Option B:** **HPV types 6 and 11** are responsible for over 90% of cases. These are "low-risk" types (non-oncogenic), though malignant transformation to squamous cell carcinoma can rarely occur (associated with HPV 16/18). * **Option D:** In Juvenile-onset RRP (JORRP), the virus is typically transmitted during **vaginal delivery** through an infected birth canal (associated with maternal genital warts/condyloma acuminata). --- ### **High-Yield Clinical Pearls for NEET-PG** * **Triad of JORRP:** Hoarseness of voice, stridor, and respiratory distress. * **Gold Standard Treatment:** Surgical excision using **CO2 Laser** or **Microdebrider**. The goal is to maintain the airway and improve voice quality, not necessarily total cure, as recurrence is common. * **Adjuvant Therapy:** Indicated if surgery is required >4 times/year. **Cidofovir** (intralesional) is the most commonly used adjuvant. * **Prevention:** The quadrivalent/nanovalent HPV vaccine is effective in reducing the incidence. * **Histopathology:** Shows a vascular connective tissue core covered by stratified squamous epithelium (finger-like projections).

Q: All of the following statements about Laryngomalacia are true EXCEPT?

Surgical tracheostomy is the treatment of choice.. **Explanation:** **Laryngomalacia** is the most common cause of congenital stridor. It occurs due to the inward collapse of supraglottic structures (epiglottis, aryepiglottic folds) during inspiration. **Why Option D is the correct answer (The False Statement):** Surgical tracheostomy is **not** the treatment of choice. In approximately 90% of cases, laryngomalacia is a self-limiting condition that resolves spontaneously by 18–24 months as the laryngeal cartilage matures. Conservative management and reassurance are the mainstays. If surgery is required (for severe cases with failure to thrive or cor pulmonale), **Supraglottoplasty** (endoscopic trimming of redundant tissue) is the procedure of choice, not tracheostomy. **Analysis of other options:** * **Option A:** It is indeed the **most common congenital anomaly** of the larynx, accounting for nearly 60% of cases of neonatal stridor. * **Option B:** The classic endoscopic finding is an **Omega-shaped (Ω) epiglottis** due to the inward folding of its lateral margins. * **Option C:** The stridor is typically **inspiratory**. It worsens during activity, feeding, or crying (increased airflow) and is characteristically **relieved when the infant is placed in the prone position** (gravity pulls the tongue and epiglottis forward, opening the airway). **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of collapse:** Aryepiglottic folds (shortened). * **Diagnosis:** Flexible fiberoptic laryngoscopy (Gold Standard) showing inspiratory collapse of supraglottic structures. * **Associated Condition:** Gastroesophageal Reflux Disease (GERD) is frequently associated and can worsen the stridor. * **Synchronous Airway Lesions:** Found in ~15% of cases; hence, a full airway evaluation is often recommended.

Q: Reinke's edema is associated with which of the following?

Smoking. **Explanation:** **Reinke’s Edema** (also known as polypoid degeneration of the vocal cords) is a condition characterized by the accumulation of gelatinous fluid in the **Reinke’s space**—a potential space between the vocal ligament and the overlying squamous epithelium (the superficial lamina propria). **Why Smoking is the Correct Answer:** The primary etiology of Reinke’s edema is **chronic irritation**, with **cigarette smoking** being the most significant risk factor (present in over 90% of cases). Chronic exposure to smoke causes increased capillary permeability and inflammation within the Reinke’s space. Because this space has limited lymphatic drainage, the fluid becomes trapped, leading to the characteristic "baggy" or "fusiform" swelling of the vocal folds. Vocal abuse (overuse) is a common secondary contributing factor. **Why Other Options are Incorrect:** * **Alcoholism:** While alcohol is a risk factor for laryngeal carcinoma, it is not a direct causative agent for Reinke’s edema. * **Malnutrition:** There is no clinical evidence linking nutritional deficiencies to the localized accumulation of fluid in the vocal folds. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Typically seen in middle-aged women who present with a progressively **low-pitched, "husky" or "man-like" voice**. * **Pathology:** Edema is restricted to the Reinke’s space because the epithelium is firmly attached to the vocal ligament at the arcuate lines. * **Treatment:** The first line of management is **smoking cessation** and voice therapy. If surgery is required, **decortication** of the vocal cord (stripping) or a "Siddharth’s pouch" incision is performed. * **Key Distinction:** Unlike vocal nodules (which are bilateral and at the junction of the anterior 1/3 and posterior 2/3), Reinke’s edema involves the entire length of the membranous vocal cord.

Q: A 4-year-old child presents with a history of hoarseness, croupy cough, and aphonia. The child has dyspnea with wheezing. What is the most probable diagnosis?

Laryngeal foreign body. ### Explanation **Correct Answer: B. Laryngeal foreign body** The clinical triad of **hoarseness, croupy cough, and aphonia** (loss of voice) specifically points toward a laryngeal pathology. When a foreign body (FB) lodges in the larynx, it causes immediate mechanical obstruction and irritation of the vocal cords, leading to aphonia and a characteristic "croupy" or barking cough. The presence of **dyspnea and wheezing** (often an inspiratory or biphasic stridor misdiagnosed as wheeze) indicates significant airway compromise. In a 4-year-old, sudden onset of these symptoms without a prodrome of fever strongly suggests an aspirated foreign body. **Why the other options are incorrect:** * **A. Asthmatic bronchitis:** While it presents with wheezing and dyspnea, it does not typically cause aphonia or a croupy cough. It is characterized by expiratory wheezing and a history of atopy. * **C. Bronchopneumonia:** This presents with high-grade fever, productive cough, and tachypnea. Aphonia is not a feature of lower respiratory tract infections. * **D. Retropharyngeal abscess:** This presents with drooling, muffled "hot potato" voice, and neck stiffness (torticollis), rather than aphonia and a croupy cough. **NEET-PG High-Yield Pearls:** * **Laryngeal FB:** Rare (5%) compared to bronchial FB (80%), but more life-threatening. * **Classic Signs:** The "Palpable Thud" and "Audible Slap" are characteristic of a **tracheal** foreign body, not laryngeal. * **Diagnosis:** Direct laryngoscopy is the gold standard for both diagnosis and removal. * **Age Group:** Most common in children aged 1–3 years due to lack of molar teeth and immature swallowing reflexes. * **Radiology:** Most foreign bodies are radiolucent (e.g., peanuts); look for indirect signs like obstructive emphysema or atelectasis.

Q: What is the primary treatment for a mobile tumor on the vocal cord?

Radiotherapy. **Explanation:** The primary treatment for a **mobile tumor on the vocal cord** (typically early-stage glottic carcinoma, T1 or T2) is **Radiotherapy**. The underlying medical concept is the preservation of **voice quality**. In early-stage laryngeal cancer where the vocal cord remains mobile, both radiotherapy and conservative surgery (like CO2 laser excision) offer similar cure rates (approx. 90%). However, radiotherapy is traditionally preferred as the primary modality because it treats the entire larynx while maintaining the structural integrity of the vocal cords, resulting in a superior functional voice outcome compared to surgical resection. **Analysis of Options:** * **Radiotherapy (Correct):** It is the treatment of choice for T1/T2 glottic lesions with mobile cords to preserve voice. * **Surgery (Incorrect):** While "Micro-laryngeal Surgery" or "Laser Cordectomy" are viable alternatives, they are often reserved for specific localized lesions or cases where radiotherapy is contraindicated. In a general NEET-PG context, RT is the standard answer for mobile cord tumors. * **Chemotherapy (Incorrect):** Chemotherapy is not used as a primary or standalone treatment for early glottic cancer. It is reserved for advanced stages (T3/T4) as part of "Organ Preservation Protocols" (Concurrent Chemoradiotherapy). **Clinical Pearls for NEET-PG:** * **Cord Mobility:** A mobile vocal cord indicates a T1 or T2 lesion. A **fixed vocal cord** signifies a T3 lesion (invasion of thyroarytenoid muscle or cricoarytenoid joint). * **Staging:** Glottic cancer is the most common laryngeal cancer and has the best prognosis due to early symptoms (hoarseness) and sparse lymphatic drainage. * **Treatment Choice:** For T1/T2, RT or Surgery are options. For T3, Concurrent Chemoradiotherapy is preferred. For T4, Total Laryngectomy is the gold standard.

Q: In the early stage of which of the following carcinomas are lymphatics not involved?

Glottic carcinoma. **Explanation:** The correct answer is **Glottic carcinoma**. This is a high-yield concept in ENT oncology based on the unique lymphatic anatomy of the larynx. **1. Why Glottic Carcinoma is correct:** The vocal cords (glottis) are unique because they are virtually **devoid of lymphatic drainage**. The Reinke’s space (subepithelial space of the vocal cord) lacks a lymphatic network. Consequently, early-stage glottic tumors (T1 and T2) rarely metastasize to regional lymph nodes. This anatomical "barrier" results in an excellent prognosis, as the disease remains localized for a long duration. Furthermore, patients present early due to hoarseness of voice. **2. Why the other options are incorrect:** * **Supraglottic carcinoma:** The supraglottis has a very rich and dense lymphatic network that drains into the deep cervical nodes. Over 40-50% of patients present with palpable lymphadenopathy at the time of diagnosis. * **Infraglottic (Subglottic) carcinoma:** Though rare, the subglottis has a significant lymphatic supply that drains to the pre-laryngeal (Delphian), pre-tracheal, and paratracheal nodes. * **Hypopharyngeal carcinoma:** This region is highly vascular and rich in lymphatics. These tumors are often "silent" and typically present at an advanced stage with early cervical lymph node metastasis. **Clinical Pearls for NEET-PG:** * **Best Prognosis:** Glottic carcinoma (due to lack of lymphatics and early symptoms). * **Worst Prognosis:** Subglottic carcinoma (due to late diagnosis and proximity to vital structures). * **Most Common Site:** Glottis is the most common site for laryngeal cancer in India and the West. * **Delphian Node:** The pre-laryngeal node, often involved in subglottic and supraglottic spread.

Question 1

What is the treatment of choice for a vocal nodule?

Accepted Answer

Microlaryngoscopic removal

Answer

Radical excision

Answer

Cryotherapy

Answer

Wait and watch

Question 2

Recurrent laryngeal nerve palsy produces vocal cord in which position?

Accepted Answer

Paramedian

Answer

Cadaveric

Answer

Abducted

Answer

Adducted

Question 3

All of the following structures are considered part of the supraglottis in the context of laryngeal cancer, except?

Accepted Answer

All of the above

Answer

Vallecula

Answer

Lower border of cricoid cartilage

Answer

Posterior commissure

Question 4

All of the following statements about recurrent laryngeal papillomatosis are true, except?

Accepted Answer

HPV6 is more virulent than HPV11.

Answer

Caused by human papilloma virus (HPV).

Answer

HPV6 and HPV11 are most commonly implicated.

Answer

Transmission to neonate occurs through contact with mother during vaginal delivery.

Question 5

All of the following statements about Laryngomalacia are true EXCEPT?

Accepted Answer

Surgical tracheostomy is the treatment of choice.

Answer

It is the most common congenital anomaly of the larynx.

Answer

It is associated with an omega-shaped epiglottis.

Answer

Stridor is increased on crying and relieved on lying prone.

Question 6

Reinke's edema is associated with which of the following?

Accepted Answer

Smoking

Answer

Alcoholism

Answer

Malnutrition

Answer

None of the above

Question 7

A 4-year-old child presents with a history of hoarseness, croupy cough, and aphonia. The child has dyspnea with wheezing. What is the most probable diagnosis?

Accepted Answer

Laryngeal foreign body

Answer

Asthmatic bronchitis

Answer

Bronchopneumonia

Answer

Retropharyngeal abscess

Question 8

What is the primary treatment for a mobile tumor on the vocal cord?

Accepted Answer

Radiotherapy

Answer

Surgery

Answer

Chemotherapy

Answer

None of the above

Question 9

In the early stage of which of the following carcinomas are lymphatics not involved?

Accepted Answer

Glottic carcinoma

Answer

Infraglottic carcinoma

Answer

Supraglottic carcinoma

Answer

Hypopharyngeal carcinoma

Question 10

What is the function of the larynx?

Accepted Answer

Immunity enhancement

Answer

Phonation

Answer

Protection of the lower respiratory tract from infection

Answer

Prevention of food regurgitation

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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