Diseases of the Larynx Practice Questions

Q: What is the drug of choice for the treatment of epiglottitis?

Ceftriaxone. **Explanation:** Acute Epiglottitis is a life-threatening medical emergency characterized by rapid inflammation of the epiglottis. While the incidence has decreased due to the Hib vaccine, the most common causative organism remains *Haemophilus influenzae* type b (Hib), followed by *Streptococcus pneumoniae* and *Staphylococcus aureus*. **Why Ceftriaxone is the Correct Choice:** Third-generation cephalosporins, specifically **Ceftriaxone**, are the drug of choice because they provide excellent coverage against beta-lactamase-producing strains of *H. influenzae* and most Gram-positive cocci. They have superior tissue penetration and a proven safety profile in pediatric populations, who are most commonly affected. **Analysis of Incorrect Options:** * **Sulphamethoxazole:** Primarily used for UTIs or PCP pneumonia; it lacks the necessary efficacy against the aggressive pathogens causing epiglottitis. * **Chloramphenicol:** Historically used for Hib infections, it is no longer the first line due to its narrow therapeutic index and the risk of severe side effects like aplastic anemia and Gray baby syndrome. * **Clindamycin:** While useful for anaerobic infections or MRSA, it does not provide adequate coverage for *H. influenzae*, the primary pathogen in epiglottitis. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** High fever, "Hot potato" voice, drooling, and the **Tripod position** (leaning forward to open the airway). * **X-ray Finding:** Lateral neck X-ray shows the **"Thumb sign"** (swollen epiglottis). * **Management Priority:** The first priority is **airway management** (intubation or tracheostomy). Do not examine the throat with a tongue depressor, as it may trigger fatal laryngospasm. * **Prophylaxis:** Rifampicin is given to close contacts of Hib-positive cases.

Q: What is the typical resting position of a vocal cord in a cadaver?

Intermediate. ### Explanation The position of the vocal cords is determined by the balance of intrinsic laryngeal muscles. In a **cadaver**, all neuro-muscular activity ceases, leading to a state of complete muscle paralysis. **1. Why "Intermediate" is Correct:** The **Intermediate (Cadaveric) position** is the neutral position where the vocal cord lies approximately **3.5 mm** away from the midline. This occurs because all intrinsic muscles—both adductors (which close the glottis) and abductors (which open it)—are non-functional. Without any muscular pull, the vocal cord assumes this midway point between full abduction and the midline. **2. Analysis of Incorrect Options:** * **Median (0 mm):** The cords are in the midline. This is seen during phonation or in bilateral recurrent laryngeal nerve palsy (where the cricothyroid muscle may still tense the cord). * **Paramedian (1.5 mm):** This is the typical position in **Recurrent Laryngeal Nerve (RLN) palsy**. The cricothyroid muscle (supplied by the Superior Laryngeal Nerve) remains intact and acts as an adductor, pulling the cord closer to the midline than the cadaveric position. * **Full Abduction (7–9 mm):** This occurs during deep inspiration, driven by the active contraction of the **Posterior Cricoarytenoid (PCA)**, the only abductor of the vocal cords. **3. Clinical Pearls for NEET-PG:** * **Semon’s Law:** States that in progressive lesions of the RLN, the abductor fibers are injured first; thus, the cord initially moves to a median/paramedian position before potentially reaching the cadaveric position if the Superior Laryngeal Nerve is also involved. * **Wagner and Grossman Hypothesis:** Explains that if the Superior Laryngeal Nerve is intact, the cord stays paramedian; if both RLN and SLN are paralyzed, the cord moves to the **Intermediate/Cadaveric** position. * **Key Distance:** Remember the "3.5 mm" rule for the intermediate position to distinguish it from the paramedian (1.5 mm).

Q: Which of the following subunits is associated with inspiratory stridor?

Supraglottic. ***Supraglottic*** - Obstruction or narrowing in the supraglottic region (above the true vocal cords), such as in **epiglottitis** or **laryngomalacia**, collapses inward during inspiration. - This physiological collapse under negative inspiratory pressure creates characteristic high-pitched airflow limitation known as **inspiratory stridor**. *Glottic* - Lesions affecting the true vocal cords (e.g., bilateral **vocal cord paralysis** or severe webbing) typically cause a relatively fixed obstruction. - Fixed obstruction at the vocal cord level generally results in a **biphasic stridor** (heard equally during both inspiration and expiration). *Subglottic* - Obstruction occurring below the vocal cords at the level of the cricoid cartilage (e.g., **croup** or **subglottic stenosis**). - Since the subglottic area is less compliant than the supraglottic area, it commonly causes a coarse, barking sound and often presents as **biphasic stridor**. *Trachea* - Lower tracheal obstruction may produce a **monophonic wheeze** or sounds related more to expiratory airflow limitation. - High or mid-tracheal lesions, especially if fixed, typically generate a relatively loud **biphasic stridor** rather than purely inspiratory stridor.

Q: Which of the following is true about laryngeal cancer stage T1bNOMO?

Both vocal cords involved, and mobile. ***Both vocal cords involved, and mobile***- The **T1** designation in glottic laryngeal cancer implies that the tumor is strictly limited to the **vocal cords** and that mobility is preserved (i.e., they are **mobile**).- The subsequent **T1b** substage defines tumors that involve **both vocal cords** (e.g., crossing the anterior or posterior commissure) while maintaining normal movement.*Both vocal cords involved and fixed*- **Vocal cord fixation** is a defining feature of **T3** glottic carcinoma, indicating deep invasion into the paralaryngeal space or underlying musculature.- This designation immediately excludes **T1** staging, which strictly requires preserved vocal cord **mobility**.*One vocal cord involved and fixed*- **Fixation** (immobility) places the tumor in **T3** or higher, regardless of tumor size or involvement of one versus both vocal cords.- **T1a** is defined by involvement of only **one vocal cord**, but critically, it must be mobile to be classified as T1.*One vocal cord involved, and mobile*- This specific description corresponds to **T1a** glottic laryngeal cancer, which involves the tumor being confined to the **glottis** and limited to only **one vocal cord**, with normal mobility.

Q: A 72-year-old female smoker presents with a long history of hoarseness and difficulty swallowing. Laryngoscopy and biopsy confirm a large, advanced squamous cell carcinoma that involves both vocal cords and extends into the subglottic region and the thyroid cartilage. The tumor is not amenable to radiation therapy alone. Based on the extent and location of the tumor, which of the following surgical procedures is most appropriate to ensure complete tumor removal with adequate margins and control the disease?

Total laryngectomy. ***Total laryngectomy*** - This procedure is the standard of care for **advanced laryngeal carcinoma (T3/T4a)** when there is extensive involvement, including the **thyroid cartilage invasion** and extension into the **subglottic region**. - Given the tumor's size, bilateral cord involvement, and lack of response to primary radiation, total laryngectomy is required to achieve complete tumor removal with **negative surgical margins**. *Partial laryngectomy* - This technique is generally restricted to **early-stage tumors (T1 or T2)** confined to one part of the larynx without substantial cartilage or subglottic spread. - Attempting a partial resection on a large, bilateral tumor with **cartilage invasion** would result in positive margins and an unacceptable risk of local recurrence. *Emergency tracheostomy* - This is a procedure performed solely to relieve **acute airway obstruction**, which may occur in advanced laryngeal cancer, but it is not a curative treatment for the malignancy itself. - It addresses the symptom (airway compromise) but fails to remove the **squamous cell carcinoma** that is threatening the patient's life. *Submental tracheostomy* - A tracheostomy is an airway management procedure, not a definitive oncologic surgery for removing a large laryngeal tumor. - A standard tracheostomy (for airway placement) is sometimes needed, but placing it specifically in the **submental region** is not the standard location for a permanent tracheostoma following curative total laryngectomy.

Q: Which of the following is shown in the image below?

Steeple sign. ***Steeple sign*** - The image shows a **frontal view of the cervical trachea**, with the subglottic region narrowing inferiorly, creating an inverted V shape, characteristic of the **steeple sign**. - This sign indicates **subglottic narrowing**, usually due to **croup (laryngotracheobronchitis)**, caused by swelling of the tracheal walls. *Thumb sign* - The **thumb sign** is seen on a **lateral neck X-ray** and refers to a swollen **epiglottis** resembling a thumb. - It is indicative of **epiglottitis**, a serious bacterial infection, and would not be visible as a steeple shape in an AP view. *Omega sign* - The **omega sign** refers to the appearance of the epiglottis in **laryngomalacia**, where the epiglottis is **tubular and elongated** with infolded lateral margins. - This is typically seen on **laryngoscopy** rather than a plain radiograph and would not present as the tracheal narrowing shown. *Lyre sign* - The **lyre sign** describes the appearance of the common carotid artery bifurcation, where the internal and external carotid arteries diverge around a **carotid body tumor**, resembling a lyre musical instrument. - This is a vascular sign seen on angiography or cross-sectional imaging and has no relevance to tracheal pathology on a plain neck X-ray.

Q: Which of the following is incorrect about the clinical condition shown below?

Nocturnal cyanosis. ***Nocturnal cyanosis*** - **Nocturnal cyanosis is NOT a typical feature of laryngomalacia**, making this the correct answer to what is incorrect about the condition. Laryngomalacia is characterized by inspiratory stridor due to collapse of supraglottic structures, but it rarely causes cyanosis. - While symptoms may worsen during sleep, frank cyanosis indicates severe obstruction or hypoxemia, which is uncommon in typical laryngomalacia. If present, it suggests severe disease requiring surgical intervention. - Most cases of laryngomalacia are mild and self-limiting without significant oxygen desaturation. *Drooling of saliva* - Drooling is also not a typical feature of laryngomalacia, as the condition involves upper airway collapse, not difficulty with saliva management or swallowing. - However, **nocturnal cyanosis is the better answer** as it more clearly represents an atypical/severe presentation, whereas drooling is simply not associated with the condition at all. *Inspiratory stridor* - **Inspiratory stridor is the hallmark symptom** of laryngomalacia, caused by collapse of supraglottic structures during inspiration, leading to turbulent airflow. - This symptom is typically exacerbated by feeding, crying, agitation, or lying supine, and usually appears within the first 2 weeks to 2 months of life. *Omega-shaped epiglottis* - An **omega-shaped (Ω-shaped) epiglottis is a classic laryngoscopic finding** in laryngomalacia, visible during flexible laryngoscopy. - This anatomical configuration, along with redundant arytenoid mucosa and shortened aryepiglottic folds, contributes to the dynamic collapse during inspiration that causes stridor.

Q: All of the following are correct about the image shown except:

High pitched expiratory stridor. ***High pitched expiratory stridor*** - The image depicts an **omega-shaped epiglottis** and collapsed aryepiglottic folds, consistent with **laryngomalacia**. - Laryngomalacia typically presents with **inspiratory stridor**, not expiratory, resulting from airway collapse during inspiration. - **This is the EXCEPT answer** - high-pitched expiratory stridor is NOT a feature of laryngomalacia. *Omega shaped epiglottis* - The image clearly shows an **omega-shaped epiglottis**, a characteristic feature of **laryngomalacia**. - This anatomical variation contributes to the collapse of supraglottic structures during inspiration. *Cry is normal* - In laryngomalacia, the **vocal cords** themselves are not affected, so the **cry typically remains normal**. - The abnormal sounds (stridor) arise from the supraglottic structures, not the vocal cord function during crying. *10% cases need surgery due to development of OSA or Cor Pulmonale* - While most cases of laryngomalacia are self-limiting, approximately **10% of infants may require surgical intervention** (supraglottoplasty). - This is usually due to severe symptoms like **obstructive sleep apnea (OSA)**, failure to thrive, or the rare development of **cor pulmonale**.

Question 1

What is the drug of choice for the treatment of epiglottitis?

Accepted Answer

Ceftriaxone

Answer

Sulphamethoxazole

Answer

Chloramphenicol

Answer

Clindamycin

Question 2

What is the most common site for a contact ulcer in the larynx?

Accepted Answer

Arytenoids

Answer

Corniculate cartilage

Answer

Anterior one-third of the vocal cord

Answer

Cricoid cartilage

Question 3

What is the typical resting position of a vocal cord in a cadaver?

Accepted Answer

Intermediate

Answer

Median

Answer

Paramedian

Answer

Full Abduction

Question 4

Which of the following subunits is associated with inspiratory stridor?

Accepted Answer

Supraglottic

Answer

Glottic

Answer

Trachea

Answer

Subglottic

Question 5

Which of the following is true about laryngeal cancer stage T1bNOMO?

Accepted Answer

Both vocal cords involved, and mobile

Answer

Both vocal cords involved and fixed

Answer

One vocal cord involved and fixed

Answer

One vocal cord involved, and mobile

Question 6

A 72-year-old female smoker presents with a long history of hoarseness and difficulty swallowing. Laryngoscopy and biopsy confirm a large, advanced squamous cell carcinoma that involves both vocal cords and extends into the subglottic region and the thyroid cartilage. The tumor is not amenable to radiation therapy alone. 
Based on the extent and location of the tumor, which of the following surgical procedures is most appropriate to ensure complete tumor removal with adequate margins and control the disease?

Accepted Answer

Total laryngectomy

Answer

Emergency tracheostomy

Answer

Submental tracheostomy

Answer

Partial laryngectomy

Question 7

Which of the following is shown in the image below?

Accepted Answer

Steeple sign

Answer

Thumb sign

Answer

Omega sign

Answer

Lyre sign

Question 8

All are correct about the procedure performed in the patient except:

Accepted Answer

Skin incision is a vertical midline incision from cricoid cartilage to suprasternal notch

Answer

Skin incision is not sutured to prevent surgical emphysema

Answer

Tracheal incision is a transverse incision starting from the first tracheal ring

Answer

Performed under general anesthesia in infants

Question 9

Which of the following is incorrect about the clinical condition shown below?

Accepted Answer

Nocturnal cyanosis

Answer

Drooling of saliva

Answer

Inspiratory stridor

Answer

Omega epiglottis

Question 10

All of the following are correct about the image shown except:

Accepted Answer

High pitched expiratory stridor

Answer

Omega shaped epiglottis

Answer

Cry is normal

Answer

10% cases need surgery due to development of OSA or Cor Pulmonale

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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