Diseases of the Larynx Practice Questions

Q: Stage IVa with thyroid cartilage invasion in laryngeal carcinoma is treated with:

Total laryngectomy with radiotherapy. ***Total laryngectomy with radiotherapy*** - **Stage IVa laryngeal carcinoma** with **thyroid cartilage invasion** is considered advanced disease requiring aggressive treatment. - **Multimodal therapy** combining surgical resection (total laryngectomy) to remove the tumor and adjuvant radiotherapy to address microscopic disease and reduce recurrence is the standard of care. *Total laryngectomy* - While a **total laryngectomy** is necessary to remove the primary tumor with cartilage invasion, it often requires additional (adjuvant) therapy like radiation to improve local control and survival rates. - Relying solely on surgery for **Stage IVa disease** may not adequately address potential microscopic spread, leading to higher recurrence rates. *Radiotherapy* - **Radiotherapy alone** is typically reserved for early-stage laryngeal cancers or as a palliative measure for advanced, unresectable disease. - In Stage IVa with **thyroid cartilage invasion**, radiation alone is insufficient due to the bulk of the disease and high risk of local recurrence. *Hemilaryngectomy* - A **hemilaryngectomy** is a partial removal of the larynx, suitable for much smaller, early-stage tumors that are confined to one side of the larynx, without cartilage invasion. - It is inadequate for **Stage IVa disease** with cartilage invasion due to the extensive nature of the tumor.

Q: Topical mitomycin C is used to aid the following treatment:

Treatment of laryngotracheal stenosis. ***Treatment of laryngotracheal stenosis*** - **Mitomycin C** is an **antimitotic** agent that inhibits DNA synthesis, reducing **fibroblast proliferation** and collagen synthesis. - In laryngotracheal stenosis, it is applied topically to inhibit scar tissue formation and recurrence after surgical or endoscopic intervention. *Endoscopic treatment of angiofibroma* - **Angiofibromas** are benign vascular tumors; their treatment focuses on surgical resection, often with **preoperative embolization** to reduce bleeding. - **Mitomycin C** is not typically used for angiofibroma, as it does not address the vascular nature or growth pattern of this tumor effectively. *Skull base osteomyelitis* - **Skull base osteomyelitis** is an aggressive bacterial infection of the skull base, primarily treated with long-term **antibiotics** and sometimes surgical debridement. - **Mitomycin C**, an antineoplastic agent, has no role in treating bacterial infections of bone. *Tonsillectomy* - **Tonsillectomy** is a surgical procedure to remove the tonsils, usually performed for recurrent tonsillitis or sleep-disordered breathing. - **Mitomycin C** is not indicated for tonsillectomy; its use would not offer benefits and could potentially hinder wound healing or cause adverse effects.

Q: Stridor in an infant is most commonly due to:

Laryngomalacia. ***Laryngomalacia*** - **Laryngomalacia** is the most common cause of **congenital inspiratory stridor** in infants, resulting from supraglottic laryngeal structures collapsing inward during inspiration. - The stridor is typically **worse when crying, feeding, or lying supine** and usually improves spontaneously by 12-18 months of age. *Foreign body aspiration* - While foreign body aspiration can cause **acute stridor**, it is an event-specific occurrence, not a persistent condition from birth, and often presents with **sudden onset choking and respiratory distress**. - Its incidence is higher in **toddlers and older children** who are mobile and exploring their environment, rather than infants. *Diphtheria* - **Diphtheria** is a rare cause of stridor due to widespread vaccination and is characterized by a **"bull neck"** and a **pseudomembrane in the pharynx**, which is distinct from the typical presentation of laryngomalacia. - The stridor associated with Diphtheria is typically progressive and can lead to severe **respiratory obstruction and systemic toxicity**. *Acute epiglottitis* - **Acute epiglottitis** typically presents with sudden onset of **high fever, dysphagia, drooling, and muffled voice** in older children, rather than stridor from birth in an infant. - Due to **Hib vaccine**, acute epiglottitis is now very rare and its stridor is usually rapidly progressive and life-threatening.

Q: Wagner's classification is related to:

Vocal cord palsy. ***Vocal cord palsy*** - **Wagner's classification** is a system used to grade the severity and prognosis of **vocal fold paralysis**. - It assesses the position, mobility, and clinical impact of **vocal cord dysfunction**. *Palatal palsy* - **Palatal palsy** involves the muscles of the soft palate and is not directly assessed by Wagner's classification. - This condition affects **swallowing and speech resonance**, which are distinct from vocal cord paralysis. *Facial palsy* - **Facial palsy**, such as **Bell's palsy**, affects the facial muscles and is classified using systems like the **House-Brackmann scale**. - It is unrelated to voice or vocal cord function. *Hypoglossal palsy* - **Hypoglossal palsy** impacts the **tongue muscles**, leading to deviation or atrophy, which affects articulation and swallowing. - It does not involve the vocal cords or larynx, thus unrelated to Wagner's classification.

Q: The preferred treatment of verrucous carcinoma of the larynx is:

Endoscopic removal. ***Endoscopic removal*** - Verrucous carcinoma is a **well-differentiated squamous cell carcinoma** with a **low metastatic potential**, making local control the primary goal. - **Endoscopic removal** (e.g., CO2 laser excision) allows for precise removal with good functional outcomes and is often curative for early-stage lesions. *Electron beam therapy* - While radiation can be used for laryngeal cancers, verrucous carcinoma has a **tendency to dedifferentiate (become more aggressive)** or develop **anaplastic transformation** after radiation therapy. - This can lead to a more aggressive, conventional squamous cell carcinoma with poorer prognosis, making it a less preferred primary treatment. *Total laryngectomy* - **Total laryngectomy** is a highly morbid procedure that involves the complete removal of the larynx. - It is reserved for extensive, deeply infiltrative tumors or cases where other treatments have failed, which is typically not the case for most verrucous carcinomas. *Partial laryngectomy* - **Partial laryngectomy** involves removing part of the larynx, aiming to preserve voice and swallowing function. - This is an option for certain laryngeal cancers, but for verrucous carcinoma, less invasive endoscopic removal is often sufficient and preferred given its non-invasive nature.

Q: Which of the following is a precancerous lesion?

Keratosis of larynx. ***Keratosis of larynx*** - **Keratosis of the larynx**, particularly with **dysplasia**, is considered a **precancerous lesion** due to the potential for malignant transformation into squamous cell carcinoma [1]. - It involves abnormal thickening and keratinization of the laryngeal mucosa, often linked to irritants like **smoking** and **alcohol** [1]. *Laryngitis sicca* - This condition involves **dryness and crusting of the laryngeal mucosa**, typically due to environmental factors or systemic drying conditions. - While uncomfortable, it is generally an **inflammatory** condition and not considered precancerous. *Scleroma larynx* - **Laryngeal scleroma** is a chronic inflammatory condition caused by infection with **Klebsiella rhinoscleromatis**, leading to granulomatous changes and fibrosis. - It results in progressive airway obstruction but is a bacterial infection and **not a precancerous lesion**. *Pachydermia of larynx* - **Pachydermia of the larynx** refers to a benign thickening of the laryngeal mucosa, often in the interarytenoid region, typically due to **chronic irritation** or reflux. - Although it indicates chronic inflammation and hyperkeratosis, it is generally considered a **benign reactive change** rather than a true precancerous condition, unless significant dysplasia is also present (which would classify it under keratosis). **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 746-747.

Q: Treatment of choice for carcinoma larynx T1N0M0 stage -

External beam radiotherapy. ***External beam radiotherapy*** - For **T1N0M0 laryngeal carcinoma**, EBRT is the **treatment of choice** as it provides excellent **local control rates (>90%)** while completely **preserving voice quality**. - It is **non-invasive** and avoids surgical complications, making it preferred over surgery for **early-stage glottic cancer** in examination contexts. *Surgery & radiotherapy* - **Combined modality treatment** is reserved for **locally advanced disease (T3-T4)** or **node-positive cases (N+)**, not for early T1N0M0 stage. - Using both treatments for T1 disease would cause **unnecessary morbidity** and **voice impairment** without improving outcomes. *Surgery* - **Transoral laser microsurgery** or **cordectomy** are effective alternatives but considered **secondary choice** in exam contexts for T1N0M0. - While equally effective, surgery carries **operative risks** and potential for **voice quality changes** compared to radiotherapy. *Radioactive implants* - **Brachytherapy** can be used for early glottic cancer but requires **specialized centers** and expertise. - **External beam radiotherapy** is more widely available and has **extensive outcome data** making it the preferred radiotherapy modality.

Q: A tracheostomised patient, with Portex tracheostomy tube, in the ward, developed sudden complete blockage of the tube. Which of the following is the best next step in the management -

Immediate removal of the tracheostomy tube. ***Immediate removal of the tracheostomy tube*** - In cases of **sudden complete tracheostomy tube blockage**, the primary concern is airway patency. Removing the tube is the quickest way to re-establish an airway, as the **tracheostomy stoma** will likely provide a path for breathing. - Delaying removal for suctioning or other interventions can lead to **critical hypoxia** and respiratory arrest if the blockage is total. *Suction of tube with saline* - While suctioning is a routine part of tracheostomy care, using saline to clear a **completely blocked tube** is unlikely to be effective and will delay definitive airway management. - The blockage, if complete and sudden, suggests a solid or highly viscous obstruction that saline alone cannot quickly resolve, potentially worsening the situation by pushing the obstruction deeper. *Suction of tube with sodium bicarbonate* - Sodium bicarbonate can be used for mucolytic purposes in some respiratory conditions, but it is not an immediate solution for a **sudden complete airway obstruction**. - Its action is too slow, and attempting to instill it into a completely blocked tube not only wastes critical time but would also be ineffective in rapidly clearing the blockage. *Jet ventilation* - Jet ventilation requires a patent airway for effective gas exchange, which is absent in a **completely blocked tracheostomy tube**. - Attempting **jet ventilation** through a blocked tube or directly into the stoma without first clearing the primary obstruction would be ineffective and could potentially cause **barotrauma**.

Q: Most common cause of intermittent stridor in a 10-day-old child shortly after birth is:

Laryngomalacia. ***Laryngomalacia*** - This is the **most common cause** of congenital stridor, typically becoming noticeable within the first few weeks of life, consistent with a 10-day-old child. - The stridor is characteristically **intermittent**, worsens with crying or feeding, and improves when prone, due to the collapse of supraglottic structures. *Hypertrophy of turbinate* - While nasal issues can cause **stertor** (a snoring sound), hypertrophy of turbinates is not a common cause of stridor in an infant. - **Stridor** originates from the larynx or trachea, not the nasal passages. *Foreign body* - An aspirated foreign body would typically cause **acute-onset stridor** that is often continuous and associated with choking or coughing spells, rather than intermittent symptoms starting shortly after birth. - This is a less likely etiology for intermittent stridor developing within the first two weeks of life. *Vocal nodule* - Vocal nodules are generally associated with **hoarseness** or a change in voice quality, and typically require chronic vocal abuse to develop. - They are exceptionally rare in neonates and would not present as intermittent stridor.

Q: All are true about tracheostomy tube except -

Removal of metallic tube in every 2-3 days. ***Removal of metallic tube in every 2-3 days*** - This statement is **false**. Metallic tracheostomy tubes, particularly Jackson tubes, are designed for **long-term placement** and typically remain in situ for extended periods (weeks to months). - The inner cannula is removed regularly for cleaning, but the outer metallic tube itself is not removed every 2-3 days as this would cause unnecessary trauma to the stoma. - Regular cleaning of the inner cannula maintains airway hygiene without disturbing the outer tube. *Made up of silver or stainless steel* - This statement is **true**. Traditional Jackson tracheostomy tubes are made of **silver**, which provides excellent durability, biocompatibility, and antimicrobial properties. - Modern metallic tubes may also be made of **stainless steel**, which can be sterilized and reused. - These materials have smooth surfaces that minimize tissue irritation and allow for long-term use. *Jackson's tube has 2 lumens* - This statement is **true**. Jackson tracheostomy tubes have a **double lumen design** consisting of an outer cannula that remains in the stoma and an **inner cannula** that can be removed for cleaning. - This design allows for maintenance of airway hygiene without disturbing the outer cannula, reducing the risk of accidental decannulation and stoma trauma. *Cuffed tube is used to prevent aspiration of pharyngeal secretion* - This statement is **true**. **Cuffed tracheostomy tubes** have an inflatable cuff that creates a seal in the trachea, primarily to **prevent aspiration** of oropharyngeal secretions and gastric contents into the lower respiratory tract. - The cuff also ensures effective positive pressure ventilation by preventing air leakage around the tube during mechanical ventilation.

Question 1

Stage IVa with thyroid cartilage invasion in laryngeal carcinoma is treated with:

Accepted Answer

Total laryngectomy with radiotherapy

Answer

Total laryngectomy

Answer

Radiotherapy

Answer

Hemilaryngectomy

Question 2

Topical mitomycin C is used to aid the following treatment:

Accepted Answer

Treatment of laryngotracheal stenosis

Answer

Endoscopic treatment of angiofibroma

Answer

Skull base osteomyelitis

Answer

Tonsillectomy

Question 3

Stridor in an infant is most commonly due to:

Accepted Answer

Laryngomalacia

Answer

Foreign body aspiration

Answer

Diphtheria

Answer

Acute epiglottitis

Question 4

Wagner's classification is related to:

Accepted Answer

Vocal cord palsy

Answer

Palatal palsy

Answer

Facial palsy

Answer

Hypoglossal palsy

Question 5

The preferred treatment of verrucous carcinoma of the larynx is:

Accepted Answer

Endoscopic removal

Answer

Electron beam therapy

Answer

Total laryngectomy

Answer

Partial laryngectomy

Question 6

Which of the following is a precancerous lesion?

Accepted Answer

Keratosis of larynx

Answer

Laryngitis sicca

Answer

Scleroma larynx

Answer

Pachydermia of larynx

Question 7

Treatment of choice for carcinoma larynx T1N0M0 stage -

Accepted Answer

External beam radiotherapy

Answer

Surgery

Answer

Radioactive implants

Answer

Surgery & radiotherapy

Question 8

A tracheostomised patient, with Portex tracheostomy tube, in the ward, developed sudden complete blockage of the tube. Which of the following is the best next step in the management -

Accepted Answer

Immediate removal of the tracheostomy tube

Answer

Suction of tube with saline

Answer

Suction of tube with sodium bicarbonate

Answer

Jet ventilation

Question 9

Most common cause of intermittent stridor in a 10-day-old child shortly after birth is:

Accepted Answer

Laryngomalacia

Answer

Hypertrophy of turbinate

Answer

Foreign body

Answer

Vocal nodule

Question 10

All are true about tracheostomy tube except -

Accepted Answer

Removal of metallic tube in every 2-3 days

Answer

Jackson's tube has 2 lumens

Answer

Cuffed tube is used to prevent aspiration of pharyngeal secretion

Answer

Made up of silver or stainless steel

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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