Diseases of the Larynx Practice Questions

Q: What is the most likely diagnosis shown in the image?

Vocal polyp. ***Vocal polyp*** - The image shows a **pedunculated or sessile lesion** on the vocal fold, often associated with a vascular component or fluid-filled appearance, typical of a vocal polyp. - Vocal polyps are typically **unilateral** and often result from acute vocal trauma or chronic phonotrauma, causing a distinct mass. *Vocal nodule* - Vocal nodules are typically **bilateral, symmetrical lesions** located on the middle third of the vocal folds, resembling calluses or bumps. - They tend to be smaller and firmer, forming due to chronic vocal abuse, unlike the larger, often unilateral lesion seen here. *Laryngomalacia* - Laryngomalacia is a **congenital anomaly** where the laryngeal structures are soft and collapse inward during inspiration, primarily affecting infants. - This condition does not present with a discrete mass on the vocal fold but rather with a generalized malformation of the larynx. *Epiglottitis* - Epiglottitis is an **inflammation and swelling of the epiglottis**, which can be life-threatening due to airway obstruction. - The image displays vocal folds and a lesion, not a swollen, cherry-red epiglottis, which would be located superior to the vocal cords.

Q: A 14-year-old teenager presents with hoarseness of voice. Which of the following is responsible for the lesion shown in the figure?

HPV. ***HPV*** - The image depicts **laryngeal papillomatosis**, characterized by **wart-like lesions** on the vocal cords, which is primarily caused by **Human Papillomavirus (HPV)** types 6 and 11. - In teenagers, this condition is typically **juvenile-onset recurrent respiratory papillomatosis**, acquired perinatally from an infected mother. *EBV* - **Epstein-Barr Virus (EBV)** is associated with infectious mononucleosis, certain lymphomas, and nasopharyngeal carcinoma, but not typically with laryngeal papillomas. - Oral manifestations of EBV infection, like **oral hairy leukoplakia**, are distinct from benign laryngeal growths. *HIV* - **Human Immunodeficiency Virus (HIV)** causes immunosuppression, increasing susceptibility to various opportunistic infections and cancers, but it does not directly cause laryngeal papillomatosis. - While HIV-positive individuals may have co-infection with HPV, HPV is the direct cause of the papillomas. *HSV* - **Herpes Simplex Virus (HSV)** is known for causing oral and genital herpes lesions, characterized by **vesicles and ulcers**. - HSV does not typically cause the **papillomatous, proliferative lesions** seen in the image, which are characteristic of HPV infection.

Q: A 60-year-old smoker presents with history of weight loss and thyroid swelling which is hard in consistency. Surgery was performed after which nerve B and D shown in the diagram got involved. All are true about the resultant condition except:

Askew position of vocal cord. ***Askew position of vocal cord*** - Vocal cord paralysis typically results in the **paramedian or median position** of the vocal cords, not an "askew" position, which is not a recognized clinical term for vocal cord positioning. - The nerves B and D are the **recurrent laryngeal nerves**, which innervate all intrinsic muscles of the larynx except the cricothyroid. Damage to both recurrent laryngeal nerves would lead to **bilateral vocal cord paralysis**. *Most common symptom is dyspnea and stridor* - **Bilateral recurrent laryngeal nerve palsy** leads to the vocal cords being fixed in a paramedian position, which significantly narrows the glottic opening. - This narrow airway causes severe **dyspnea** (difficulty breathing) and inspiratory **stridor** (a high-pitched crowing sound during inhalation), which are life-threatening symptoms requiring immediate intervention. *Most common cause is thyroid surgery* - The most common cause of **bilateral recurrent laryngeal nerve paralysis** is **thyroid surgery** due to iatrogenic trauma or transection of the nerves during the procedure. - Other causes include **malignant infiltration** of the thyroid or surrounding structures, and rarely **bilateral intubation trauma**. - Given the clinical scenario of a patient with thyroid swelling undergoing surgery, iatrogenic injury during thyroidectomy is the most likely cause. *Kashima operation with carbon dioxide laser* - The **Kashima operation**, involving posterior cordectomy with a **CO2 laser**, is a surgical procedure used to widen the glottic airway in cases of bilateral vocal cord paralysis. - This procedure aims to create a larger breathing passage by removing a portion of the posterior vocal cord, thereby alleviating dyspnea and stridor.

Q: A 10-year-old girl complains of hoarseness and stridor. Ambulatory pH monitoring is normal. Laryngoscopy image shows:

Recurrent respiratory papillomatosis. ***Recurrent respiratory papillomatosis*** - The image shows a **wart-like lesion** on the vocal cord, which is characteristic of **recurrent respiratory papillomatosis (RRP)**, especially in a child with hoarseness and stridor. - RRP is caused by the **human papillomavirus (HPV)** and can affect the airway, leading to vocal changes and breathing difficulties. - This is the most common benign laryngeal tumor in children and typically presents with progressive hoarseness and stridor. *Vocal cord polyp* - A vocal cord polyp is typically a **stalked, unilateral lesion**, often associated with vocal trauma or heavy voice use, and usually appears as a fluid-filled sac. - While it can cause hoarseness, the appearance in the image with multiple, nodular growths in the glottic area is less consistent with a single polyp. - Polyps are more common in adults than children. *Vocal cord nodules* - Vocal cord nodules are typically **bilateral, symmetrical lesions** located at the junction of the anterior and middle third of the vocal cords, resembling calluses. - They are usually caused by **voice abuse** (e.g., screaming, prolonged singing) and are less likely to present with the cauliflower-like appearance shown. - Nodules appear smooth and do not have the exophytic, warty appearance of papillomas. *Intubation granuloma* - An intubation granuloma is a **benign lesion** that forms at the posterior true vocal cord or arytenoid cartilage due to **mucosal trauma** from endotracheal intubation. - This patient's history does not suggest recent intubation, and the appearance in the image is more consistent with papilloma than a granuloma. - Granulomas typically appear as smooth, pedunculated masses at the posterior glottis.

Q: A 30-year-old vegetable vendor complains of repeated episodes of hoarseness and pain in the neck on speaking. The laryngoscopy image of the patient shows:

Vocal nodules. ***Vocal nodules*** - The image shows **bilateral, symmetrical lesions** on the vocal cords, characteristic of vocal nodules, commonly known as "singer's nodes" or "screamer's nodes." - The patient's profession as a **vegetable vendor**, involving frequent and loud speaking, is a classic risk factor for vocal misuse leading to nodule formation. *Vocal polyp* - A vocal polyp is typically a **unilateral lesion**, often larger and more reddish than nodules. - While it can also cause hoarseness, the **bilateral and symmetrical nature** seen in the image points away from a polyp. *Reinke's edema* - Reinke's edema involves diffuse **swelling and fluid accumulation** in Reinke's space (superficial lamina propria) of both vocal cords, often associated with smoking. - The image does not show the characteristic **"sac-like" or "baggy" appearance** of generalized edema. *Intubation granuloma* - An intubation granuloma results from **trauma during endotracheal intubation** and is typically located on the posterior aspect of the vocal cords (arytenoid area). - The patient's history does not mention intubation, and the **location and appearance** in the image are not typical for a granuloma.

Q: The following image shows:

Respiratory papillomatosis. ***Respiratory papillomatosis*** - The image displays multiple **wart-like growths** on the vocal cords, characteristic of **respiratory papillomatosis**, which is caused by the **human papillomavirus (HPV)**. - These lesions often have an **irregular, cauliflower-like appearance** and can recur even after removal, making it a challenging condition to manage. *Vocal nodule* - Vocal nodules are typically **bilateral, symmetrical lesions** located at the junction of the anterior and middle thirds of the vocal cords. - They are usually **smooth, small, and whitish**, resulting from chronic vocal abuse, unlike the irregular and multiple growths seen in the image. *Vocal polyp* - Vocal polyps are typically **unilateral lesions** that can appear as sessile or pedunculated masses on a vocal cord. - They are often **larger than nodules** and may have a reddish or gelatinous appearance, but they usually occur singly, not as multiple diffuse growths like those pictured. *TB of vocal cords* - Tuberculosis of the vocal cords often presents with **ulcerative lesions**, granulomas, or diffuse inflammation, and may be accompanied by other signs of pulmonary TB. - The lesions caused by TB are generally **not papillomatous** or wart-like in nature, differentiating them from the appearance in the image.

Q: Which is the most common laryngeal abnormality that produces laryngeal stridor in a newborn?

Laryngomalacia. ***Laryngomalacia*** - **Laryngomalacia** is the most common cause of **congenital laryngeal stridor**, accounting for 60-70% of cases. - It results from the **floppiness of supraglottic structures** (epiglottis and arytenoids) that collapse inward during inspiration, causing stridor. *Congenital vocal cord paralysis* - While it can cause stridor, **congenital vocal cord paralysis** is much less common than laryngomalacia. - It typically results from neurological issues, and the stridor quality may differ. *Congenital web* - A **congenital web** is a rare cause of stridor, usually presenting with a **high-pitched persistent stridor** and often a weak cry. - The severity depends on the extent of the web across the glottis. *Congenital subglottic stenosis* - **Congenital subglottic stenosis** is the third most common cause of congenital stridor (after laryngomalacia and vocal cord paralysis). - It is characterized by narrowing of the airway below the vocal cords and often presents with biphasic stridor and recurrent croup-like symptoms.

Q: A localized nodule of squamous cell carcinoma in the vocal cord is best treated by

Laser therapy. ***Laser therapy (Transoral Laser Microsurgery)*** - **CO2 laser excision** is an excellent first-line treatment for localized T1a squamous cell carcinoma of the vocal cord, offering **>90% cure rates**. - Advantages include: **precise tumor removal**, immediate pathological assessment with margin evaluation, **excellent voice preservation**, and shorter treatment duration compared to radiotherapy. - **Transoral laser microsurgery (TLM)** allows for cord-sparing procedures that maintain vocal function while achieving complete oncological resection. *Radiotherapy* - **Important Note:** **Radiotherapy is EQUALLY effective** as laser therapy for early T1 glottic cancer, with comparable **5-year local control rates (>90%)** and voice quality outcomes. - Both laser surgery and radiotherapy are **guideline-recommended first-line treatments** (NCCN, ESMO guidelines). - Choice between the two depends on tumor characteristics (anterior commissure involvement), patient preference, institutional expertise, and functional outcomes. - In examination contexts, laser therapy may be preferred as it provides histopathological confirmation and is often considered more definitive for "localized nodules." *Cryosurgery* - **Cryosurgery** is rarely used for vocal cord lesions due to **unpredictable tissue destruction**, potential for severe **vocal cord scarring**, and inability to obtain tissue for pathological margin assessment. - Not a standard treatment option for laryngeal cancer. *Surgical excision* - This term is ambiguous as **laser excision IS a form of surgical excision**. - If referring to **open surgical approaches** (laryngofissure, cordectomy via external approach), these are more invasive than transoral laser surgery and are reserved for larger tumors or salvage situations. - Traditional "cold steel" endoscopic excision is less precise than laser and can cause more trauma and scarring.

Q: Which among the following is not used in post laryngectomy rehabilitation?

Tracheostomy tube. ***Tracheostomy tube*** - Following total laryngectomy, the **trachea is permanently diverted** to form a permanent stoma in the neck for breathing. - In the context of **post-laryngectomy rehabilitation**, the focus is on **voice restoration** methods rather than airway management devices. - While laryngectomy tubes or stoma buttons may be used temporarily for **stoma care** (preventing stenosis, maintaining patency), traditional **tracheostomy tubes are not part of voice rehabilitation** protocols. - The patient breathes directly through the permanent stoma, and rehabilitation centers on restoring communication ability. *Esophageal speech* - **Esophageal speech** is a voice rehabilitation method where air is injected into the esophagus and then expelled, vibrating the pharyngoesophageal segment to produce sound. - It requires no external devices, only extensive training, and can provide functional voice for communication. - This is one of the **three main voice restoration options** after laryngectomy. *Tracheoesophageal puncture* - **Tracheoesophageal puncture (TEP)** with voice prosthesis is the **gold standard** for voice rehabilitation post-laryngectomy. - A small fistula is created between trachea and esophagus, and a one-way valve (voice prosthesis) is inserted. - Air from the lungs is diverted through the prosthesis into the esophagus, vibrating the pharyngoesophageal segment to produce speech. - Provides the **most natural-sounding voice** among rehabilitation options. *Electrolarynx* - An **electrolarynx** is an external, battery-operated device held against the neck or placed intraorally that generates vibrations. - The vibrations are articulated by the mouth and tongue to produce speech. - Provides **immediate communication** post-laryngectomy, though the voice quality is mechanical or robotic.

Q: Not true about glottic carcinoma

Has worst prognosis. ***Has worst prognosis*** - Glottic carcinoma generally has a **good prognosis** due to its early presentation with hoarseness and relative lack of lymphatic dissemination. - The statement that it has the **worst prognosis** among laryngeal carcinomas is incorrect; supraglottic and subglottic carcinomas often have poorer prognoses. *Is most common site in carcinoma larynx* - The **glottis** (true vocal cords) is indeed the **most common site** for laryngeal squamous cell carcinoma, accounting for about 60-70% of cases. - This anatomical location is prone to neoplastic changes due to exposure to carcinogens. *Presents early* - Glottic carcinoma typically presents **early** with **hoarseness of voice** as the tumor interferes with vocal cord vibration. - This early symptom often leads to prompt medical attention, allowing for early diagnosis and treatment. *Most common in males* - Laryngeal carcinoma, including glottic carcinoma, is significantly **more common in males** than females, with a male-to-female ratio of about 4:1. - This gender disparity is primarily attributed to higher rates of smoking and alcohol consumption in men. *Has good prognosis due to least lymphatic supply.* - The **glottis** has a relatively **sparse lymphatic drainage** compared to the supraglottis and subglottis. - This limited lymphatic supply leads to a lower risk of **early nodal metastasis**, contributing to the overall good prognosis.

Question 1

What is the most likely diagnosis shown in the image?

Accepted Answer

Vocal polyp

Answer

Vocal nodule

Answer

Laryngomalacia

Answer

Epiglottitis

Question 2

A 14-year-old teenager presents with hoarseness of voice. Which of the following is responsible for the lesion shown in the figure?

Accepted Answer

HPV

Answer

EBV

Answer

HIV

Answer

HSV

Question 3

A 60-year-old smoker presents with history of weight loss and thyroid swelling which is hard in consistency. Surgery was performed after which nerve B and D shown in the diagram got involved. All are true about the resultant condition except:

Accepted Answer

Askew position of vocal cord

Answer

Most common symptom is dyspnea and stridor

Answer

Most common cause is thyroid surgery

Answer

Kashima operation with carbon dioxide laser

Question 4

A 10-year-old girl complains of hoarseness and stridor. Ambulatory pH monitoring is normal. Laryngoscopy image shows:

Accepted Answer

Recurrent respiratory papillomatosis

Answer

Vocal cord polyp

Answer

Vocal cord nodules

Answer

Intubation granuloma

Question 5

A 30-year-old vegetable vendor complains of repeated episodes of hoarseness and pain in the neck on speaking. The laryngoscopy image of the patient shows:

Accepted Answer

Vocal nodules

Answer

Vocal polyp

Answer

Reinke's edema

Answer

Intubation granuloma

Question 6

The following image shows:

Accepted Answer

Respiratory papillomatosis

Answer

Vocal nodule

Answer

Vocal polyp

Answer

TB of vocal cords

Question 7

Which is the most common laryngeal abnormality that produces laryngeal stridor in a newborn?

Accepted Answer

Laryngomalacia

Answer

Congenital vocal cord paralysis

Answer

Congenital web

Answer

Congenital subglottic stenosis

Question 8

A localized nodule of squamous cell carcinoma in the vocal cord is best treated by

Accepted Answer

Laser therapy

Answer

Cryosurgery

Answer

Radiotherapy

Answer

Surgical excision

Question 9

Which among the following is not used in post laryngectomy rehabilitation?

Accepted Answer

Tracheostomy tube

Answer

Esophageal speech

Answer

Tracheoesophageal puncture

Answer

Electrolarynx

Question 10

Not true about glottic carcinoma

Accepted Answer

Has worst prognosis

Answer

Is most common site in carcinoma larynx

Answer

Presents early

Answer

Most common in males

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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