Diseases of the Larynx — MCQs

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 11: All of the following statements about recurrent laryngeal papillomatosis are true, except?

A. Caused by human papilloma virus (HPV).
B. HPV6 and HPV11 are most commonly implicated.
C. HPV6 is more virulent than HPV11. (Correct Answer)
D. Transmission to neonate occurs through contact with mother during vaginal delivery.

Explanation: ### **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).

Question 12: Which muscle is the abductor of the vocal cords, and paralysis of which can lead to suffocation?

A. Posterior cricoarytenoid (Correct Answer)
B. Cricothyroid
C. Lateral cricoarytenoid
D. Interarytenoid

Explanation: ### Explanation The correct answer is **A. Posterior cricoarytenoid (PCA)**. #### 1. Why Posterior Cricoarytenoid is Correct The **Posterior Cricoarytenoid** is the **sole abductor** of the vocal cords. It originates from the posterior surface of the cricoid lamina and inserts into the muscular process of the arytenoid cartilage. When it contracts, it rotates the arytenoids laterally, opening the glottis (rima glottidis). * **Clinical Significance:** Because it is the only muscle that opens the airway, bilateral paralysis of the PCA (often due to bilateral Recurrent Laryngeal Nerve injury) results in the vocal cords remaining in the midline (adducted position). This leads to acute airway obstruction and **suffocation**, necessitating an emergency tracheostomy. #### 2. Why Other Options are Incorrect * **B. Cricothyroid:** This is the **tensor** of the vocal cords. It is the only intrinsic laryngeal muscle supplied by the **External Laryngeal Nerve**. * **C. Lateral cricoarytenoid:** This is the primary **adductor** of the vocal cords (closes the glottis). * **D. Interarytenoid:** This muscle also acts as an **adductor** by pulling the two arytenoid cartilages together, closing the posterior part of the glottis. #### 3. High-Yield Clinical Pearls for NEET-PG * **"Safety Muscle of the Larynx":** Posterior Cricoarytenoid (because it keeps the airway open). * **Semon’s Law:** In progressive nerve lesions, the abductor fibers (PCA) are more vulnerable and paralyzed earlier than the adductor fibers. * **Nerve Supply:** All intrinsic muscles of the larynx are supplied by the **Recurrent Laryngeal Nerve (RLN)**, EXCEPT the **Cricothyroid**, which is supplied by the External Laryngeal Nerve. * **Wagner and Grossman Hypothesis:** If the RLN is injured but the External Laryngeal Nerve is intact, the cricothyroid muscle keeps the vocal cord in a median/paramedian position.

Question 13: All of the following statements about Laryngomalacia are true EXCEPT?

A. It is the most common congenital anomaly of the larynx.
B. It is associated with an omega-shaped epiglottis.
C. Stridor is increased on crying and relieved on lying prone.
D. Surgical tracheostomy is the treatment of choice. (Correct Answer)

Explanation: **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.

Question 14: Which of the following is true about juvenile respiratory papillomatosis?

A. It commonly affects children.
B. The lower respiratory tract can be involved.
C. It may resolve spontaneously.
D. All of the above. (Correct Answer)

Explanation: **Explanation:** Juvenile Recurrent Respiratory Papillomatosis (JRRP) is the most common benign neoplasm of the larynx in children, typically caused by **Human Papillomavirus (HPV) types 6 and 11**. * **Option A is correct:** It primarily affects children (usually diagnosed between ages 2 and 5). It is thought to be acquired during childbirth via an infected birth canal (maternal genital warts). * **Option B is correct:** While the larynx (specifically the true vocal cords) is the most common site, the disease can show "distal spread." In about 5% of cases, it involves the trachea, bronchi, and even the lung parenchyma, which significantly worsens the prognosis. * **Option C is correct:** A characteristic feature of the juvenile form is its unpredictable course. While it is known for aggressive recurrence requiring multiple surgeries, many cases undergo **spontaneous remission** during puberty. **Clinical Pearls for NEET-PG:** * **Triad of Symptoms:** Hoarseness of voice (most common), stridor, and respiratory distress. * **Gold Standard Treatment:** Surgical excision using **CO2 Laser** or **Microdebrider**. The goal is to maintain the airway, not necessarily to cure the virus. * **Adjuvant Therapy:** Cidofovir (antiviral) is often used for aggressive or rapidly recurring cases. * **Malignant Transformation:** Although rare (<1%), it can transform into Squamous Cell Carcinoma, especially in patients with a history of smoking or radiation exposure. * **Adult vs. Juvenile:** Adult-onset papillomatosis is usually solitary, whereas the juvenile form is typically multiple and more aggressive.

Question 15: Reinke's edema is associated with which of the following?

A. Alcoholism
B. Smoking (Correct Answer)
C. Malnutrition
D. None of the above

Explanation: **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.

Question 16: What is the primary treatment for a mobile tumor on the vocal cord?

A. Surgery
B. Chemotherapy
C. Radiotherapy (Correct Answer)
D. None of the above

Explanation: **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.

Question 17: In the early stage of which of the following carcinomas are lymphatics not involved?

A. Glottic carcinoma (Correct Answer)
B. Infraglottic carcinoma
C. Supraglottic carcinoma
D. Hypopharyngeal carcinoma

Explanation: **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 18: Nodal metastases are absent in which of the following laryngeal carcinomas?

A. Supraglottic carcinoma
B. Glottic carcinoma (Correct Answer)
C. Subglottic carcinoma
D. All of the above

Explanation: **Explanation:** The correct answer is **Glottic carcinoma** because of the unique lymphatic anatomy of the vocal folds. **1. Why Glottic Carcinoma is the correct answer:** The true vocal cords (glottis) are characterized by a **paucity of lymphatic drainage**. The free edge of the vocal cord is virtually devoid of lymphatics (Reinke’s space). Consequently, early glottic tumors (T1 and T2) rarely metastasize to regional lymph nodes (incidence <1%). Additionally, glottic tumors present early with hoarseness of voice, leading to earlier diagnosis compared to other sites. **2. Why other options are incorrect:** * **Supraglottic Carcinoma:** This region has a very rich and dense lymphatic network. About 40-50% of patients present with clinically palpable cervical lymph nodes (Level II, III, and IV) at the time of diagnosis. Bilateral metastasis is also common. * **Subglottic Carcinoma:** While rare, the subglottis has a significant lymphatic drainage that leads to the prelaryngeal (Delphian), paratracheal, and deep cervical nodes. Metastasis occurs in approximately 20% of cases. **Clinical Pearls for NEET-PG:** * **Best Prognosis:** Glottic carcinoma has the best prognosis among all laryngeal cancers due to sparse lymphatics and early symptoms. * **Most Common Site:** Glottis is the most common site for laryngeal carcinoma in India and worldwide. * **Delphian Node:** The prelaryngeal node, often involved in subglottic or anterior commissure spread, is a high-yield clinical sign. * **Staging Tip:** A glottic tumor with fixed vocal cords is staged as **T3**.

Question 19: Singer's nodule is MOST commonly seen at which location on the vocal cords?

A. Junction of the anterior two-thirds and posterior one-third of the vocal cords
B. Junction of the anterior one-third and posterior two-thirds of the vocal cords (Correct Answer)
C. Anywhere on the vocal cords
D. Middle of the anterior one-third and two-thirds of the vocal cords

Explanation: **Explanation:** **Singer’s Nodules (Vocal Nodules)** are benign, inflammatory callous-like thickenings that occur due to chronic vocal abuse or misuse. **Why Option B is Correct:** The vocal cord is divided into a **membranous part** (anterior 2/3) and a **cartilaginous part** (posterior 1/3). The point of maximum vibration and mechanical trauma during phonation occurs at the **midpoint of the membranous part**. Anatomically, this midpoint corresponds to the **junction of the anterior one-third and posterior two-thirds** of the entire vocal cord. This is the site of maximum friction, leading to localized edema and subsequent fibrosis. **Why Other Options are Incorrect:** * **Option A:** The junction of the anterior 2/3 and posterior 1/3 is the site of the **vocal process of the arytenoid**. This is the typical location for **Intubation Granulomas** or Contact Ulcers, not nodules. * **Option C:** Nodules are site-specific due to the physics of vibration; they do not occur randomly. * **Option D:** This is a confusing anatomical description that does not correspond to the standard clinical landmark for maximum glottic strike. **High-Yield Clinical Pearls for NEET-PG:** * **Appearance:** They are typically **bilateral and symmetrical**. * **Demographics:** Most common in male children (screaming) and adult females (teachers, singers). * **Early vs. Late:** Early nodules are soft/reddish; chronic nodules are firm/white due to fibrosis. * **Treatment:** The primary treatment is **Voice Therapy**. Surgery (Microlaryngeal surgery) is reserved only for large, persistent, or fibrotic nodules.

Question 20: Which of the following is NOT true about laryngomalacia?

A. Omega shaped epiglottis
B. Reassurance of the patient is the treatment of choice
C. Condition is first noticed in the first few weeks of life
D. Expiratory stridor (Correct Answer)

Explanation: **Laryngomalacia** is the most common congenital anomaly of the larynx and the most frequent cause of congenital stridor in infants. ### **Explanation of the Correct Option** * **D. Expiratory stridor:** This is the **incorrect** statement. Laryngomalacia is characterized by **Inspiratory stridor**. * **Pathophysiology:** The condition involves excessive flaccidity of the supraglottic structures (epiglottis, aryepiglottic folds). During **inspiration**, the negative pressure created in the airway causes these structures to collapse inward, obstructing the glottic opening and producing a high-pitched inspiratory sound. Expiratory stridor is typically seen in lower airway obstructions (e.g., tracheomalacia). ### **Analysis of Other Options** * **A. Omega-shaped epiglottis:** This is a classic endoscopic finding. The lateral borders of the epiglottis curl inwards, creating a Greek letter Omega (Ω) shape. Other findings include short aryepiglottic folds and bulky arytenoids. * **B. Reassurance is the treatment of choice:** Most cases (approx. 90%) are mild and self-limiting. The stridor usually peaks at 6–9 months and resolves spontaneously by 18–24 months as the laryngeal cartilage matures. * **C. Noticed in the first few weeks of life:** While it is a congenital condition, the stridor is rarely present at birth. It typically manifests within the first 2 to 4 weeks of life and increases in intensity when the child is supine, crying, or feeding. ### **High-Yield Clinical Pearls for NEET-PG** * **Diagnosis:** Flexible fiberoptic laryngoscopy (in an awake patient) is the gold standard. * **Positioning:** Stridor **improves in the prone position** (as gravity pulls the structures forward) and worsens in the supine position. * **Surgical Management:** Reserved for severe cases (failure to thrive, cor pulmonale, or severe apnea). The procedure of choice is **Supraglottoplasty**. * **Associated Condition:** Gastroesophageal reflux (GERD) is frequently associated and can worsen the edema and stridor.

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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