Diseases of the Larynx Practice Questions

Q: Most common benign lesion of vocal cord in pediatric age group is

Juvenile papillomatosis. ***Juvenile papillomatosis*** - This condition, caused by the **human papillomavirus (HPV)**, is the most common benign laryngeal tumor in children. - It presents with **recurrent wart-like lesions** on the vocal cords, leading to hoarseness and airway obstruction. *Chondroma* - This is a rare, **benign cartilaginous tumor** that can affect the larynx, but it is exceedingly uncommon in children. - It is more commonly seen in adults and typically arises from the **cricoid cartilage**. *Granular cell tumor* - This is a rare, usually benign tumor originating from **Schwann cells**, which can occur in various locations including the larynx. - It is much more common in **adults** and is distinctly rare in the pediatric age group. *Solitary papilloma* - While papillomas can affect the vocal cords, the term "solitary papilloma" more commonly refers to the **adult form of papillomatosis** (often single lesions) rather than the multiple, recurrent lesions seen in children. - In children, the lesions are typically **multiple and recurrent**, hence "juvenile" and "papillomatosis" (multiple papillomas).

Q: True about recurrent respiratory papillomatosis (multiple papillomatosis) -

HPV is causative agent. ***HPV is causative agent*** - **Human papillomavirus (HPV)** is the primary etiologic agent for recurrent respiratory papillomatosis (RRP), also known as laryngeal papillomatosis. - HPV types **6** and **11** are most commonly associated with RRP (>90% of cases), leading to benign, wart-like growths in the respiratory tract. - This is the most fundamental and defining characteristic of RRP. *It is premalignant* - RRP is a **benign** condition, not a premalignant lesion. - Malignant transformation is extremely rare (<1%), typically associated with HPV types **16** and **18**, radiation exposure, or chronic inflammation [1]. - The vast majority of cases remain benign throughout, so classifying RRP as "premalignant" is incorrect. *Surgical excision is treatment of choice* - While **surgical excision** (laser surgery, microdebrider) is indeed the primary/mainstay treatment for RRP to debulk lesions and maintain airway patency, this statement is technically true. - However, in the context of identifying the "most characteristic" feature, HPV etiology is more fundamental than treatment modality. - Adjuvant therapies like **bevacizumab**, **cidofovir**, or **interferon** may be used for recurrent cases but are not first-line. *It can occur at any age* - This is technically true - RRP exhibits a **bimodal age distribution** with juvenile-onset RRP (JORRP, peak before age 5) and adult-onset RRP (AORRP, peak 20-40 years). - However, the bimodal pattern means it has specific age predilections rather than uniform distribution across all ages. - HPV etiology remains the more definitive characteristic. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 746-747.

Q: A high tracheostomy may be indicated in:

Severe bilateral vocal cord paralysis. ***Severe bilateral vocal cord paralysis*** - **High tracheostomy** may be indicated in severe bilateral vocal cord paralysis, particularly when both cords are paralyzed in the **median (adducted) position**, causing critical airway obstruction. - A high tracheostomy is performed at the level of the **2nd or 3rd tracheal ring**, closer to the site of obstruction at the glottic level, providing immediate airway access. - This can serve as temporary relief while definitive treatments like **arytenoidectomy, cordectomy, or vocal cord lateralization** are planned. - In emergency situations, high tracheostomy or cricothyroidotomy may be life-saving. *Advanced carcinoma of the larynx* - High tracheostomy is **contraindicated** in laryngeal carcinoma as it may: - Transect through tumor tissue - Cause tumor seeding in the tracheal stoma - Compromise subsequent **total laryngectomy** procedures - **Low tracheostomy** (below the tumor, at 4th-5th tracheal ring) is the standard approach to secure the airway while avoiding tumor interference. *Chronic scleroma involving the larynx* - Scleroma typically causes **subglottic stenosis** and involves extensive tracheal disease. - **Low tracheostomy** is preferred to bypass the diseased area completely. - A high tracheostomy would be too close to the pathological process, risking inadequate airway and complications. *Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)* - Tracheostomy is generally **avoided** in RRP due to the significant risk of **seeding papillomas** into the tracheal stoma and lower airways. - Management focuses on **repeated endoscopic laser ablation** or surgical excision to preserve laryngeal function. - If tracheostomy is absolutely necessary, meticulous technique and close follow-up are required.

Q: Inspiratory stridor is due to lesions of:

Subglottis. ***Subglottis*** - **Inspiratory stridor** is classically associated with **subglottic lesions**, such as **croup (laryngotracheobronchitis)** and **subglottic stenosis**. - The **subglottis** is the **narrowest part of the pediatric airway**, making it particularly susceptible to significant obstruction from inflammation or narrowing. - During inspiration, the negative intrathoracic pressure causes **dynamic collapse** of the subglottic region when narrowed, producing characteristic **high-pitched inspiratory stridor**. - Common causes: **Croup**, subglottic stenosis, subglottic hemangioma. *Supraglottis* - Supraglottic lesions (epiglottis, aryepiglottic folds) can also cause **inspiratory stridor**, particularly in **acute epiglottitis**. - However, supraglottic pathology more commonly presents with **muffled voice** (hot potato voice), **dysphagia**, **drooling**, and **tripod positioning**. - The stridor from supraglottic lesions tends to be **lower-pitched** and is often accompanied by more prominent systemic symptoms. *Trachea* - Tracheal lesions typically produce **biphasic stridor** (both inspiratory and expiratory phases) due to fixed obstruction in the main conducting airway. - The trachea is a more rigid structure; obstruction produces a **harsh, lower-pitched** sound heard in both respiratory phases. - Examples: tracheal stenosis, tracheomalacia, tracheal tumors. *Bronchi* - Bronchial lesions cause **expiratory wheezing** rather than stridor, due to dynamic collapse of small airways during exhalation. - Bronchial obstruction affects the lower airways and presents as **polyphonic wheeze** rather than the monophonic sound of stridor.

Q: A 45-year-old patient presents with persistent hoarseness for 3 months. Which finding on indirect laryngoscopy is most concerning for malignancy?

Unilateral cord paralysis. ***Unilateral cord paralysis*** - **Unilateral cord paralysis** can be an indicator of an underlying malignancy impinging on the **recurrent laryngeal nerve**, which innervates the vocal cords. - The **persistent hoarseness** for 3 months, combined with paralysis, raises significant concern for a malignant process in the head, neck, or chest. *Reinke's edema* - **Reinke's edema** is typically associated with **chronic irritation** like smoking and presents as a swollen, gelatinous fluid collection in the superficial lamina propria. - While it causes hoarseness, it is a **benign condition** and not directly indicative of malignancy. *Bilateral polyps* - **Vocal cord polyps** are typically **benign lesions** often caused by vocal trauma or abuse, and while they can cause hoarseness, they are not usually a direct sign of malignancy, especially when bilateral. - While requiring management, polyps themselves do **not raise immediate concern for cancer** compared to paralysis. *Vocal cord nodules* - **Vocal cord nodules** (singer's nodules) are benign, bilateral lesions caused by **vocal abuse** and are a common cause of hoarseness. - They are a benign condition and do not suggest an underlying malignancy at their core.

Q: A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?

Direct laryngoscopy with biopsy. ***Direct laryngoscopy with biopsy*** - A definitive diagnosis of a vocal cord mass requires **histological examination** to rule out malignancy, especially given the patient's risk factors (age, smoking) and symptoms (hoarseness, dysphagia, weight loss). - **Direct laryngoscopy** allows for a thorough, magnified view of the mass and precise biopsy collection, which is superior to flexible laryngoscopy alone for definitive diagnosis and staging. *MRI of neck* - While MRI can provide excellent soft tissue detail for **staging** a known malignancy, it cannot provide a **histological diagnosis**. - It would typically be performed after a biopsy confirms malignancy to assess the extent of the tumor and potential spread. *CT scan of neck* - A CT scan is useful for evaluating **bony involvement**, lymph node status, and tumor extension for **staging purposes**, but it is not a diagnostic tool for identifying the specific type of tissue or cell pathology. - Like MRI, a CT scan would generally follow a biopsy confirming malignancy. *Radiotherapy* - **Radiotherapy** is a treatment modality for laryngeal cancer, not a diagnostic step. - Initiating treatment without a definitive histological diagnosis of malignancy would be inappropriate and potentially harmful.

Q: A 50-year-old male with a long smoking history presents with a 2-month history of hoarseness, ear pain, and hemoptysis. Laryngoscopy reveals a mass on the vocal cords, and a chest X-ray shows a suspicious nodule. What is the most likely diagnosis?

Laryngeal carcinoma. ***Laryngeal carcinoma*** - The combination of **hoarseness, ear pain, and hemoptysis** in a patient with a **long smoking history** is highly suggestive of **laryngeal carcinoma**. - **Hoarseness** is the cardinal symptom of glottic laryngeal cancer, while **ear pain** (referred otalgia via Arnold's nerve) suggests advanced disease. - **Laryngoscopy identifying a vocal cord mass** provides direct visualization of the tumor. - The **suspicious nodule on chest X-ray** may represent a **synchronous primary lung cancer** (both share smoking as a major risk factor), **distant metastasis**, or requires further evaluation. Smokers are at high risk for multiple aerodigestive tract malignancies. *Tuberculosis* - While **hemoptysis** and a **suspicious nodule on chest X-ray** can be seen in tuberculosis, **hoarseness** and **ear pain** are not typical primary symptoms. - Laryngeal tuberculosis is rare and usually secondary to pulmonary TB with **constitutional symptoms** like fever, night sweats, and weight loss, which are not mentioned. - A **vocal cord mass** would be unusual for TB without systemic features. *Pneumonia* - **Pneumonia** typically presents with acute symptoms such as **cough, fever, dyspnea, and chills**. - **Hoarseness** and **ear pain** are not characteristic features of uncomplicated pneumonia. - A **mass on the vocal cords** is not associated with pneumonia, and the **2-month duration** is too prolonged for typical bacterial pneumonia. *Chronic bronchitis* - **Chronic bronchitis** is defined by a **chronic productive cough** for at least three months a year for two consecutive years. - While common in smokers, it typically does not cause **ear pain, hemoptysis**, or a **vocal cord mass**. - Chronic bronchitis does not produce discrete masses on laryngoscopy, differentiating it from a malignant process.

Q: What is the treatment of choice for a patient with acute epiglottitis?

Intravenous antibiotics. ***Intravenous antibiotics*** - Acute epiglottitis is a rapidly progressive and potentially life-threatening bacterial infection, primarily affecting the **epiglottis** and surrounding structures. - **Intravenous antibiotics** are crucial for prompt treatment to prevent airway obstruction and systemic spread, as oral absorption may be delayed or insufficient. *Oral antibiotics* - **Oral antibiotics** are inappropriate for acute epiglottitis due to the acute and severe nature of the infection. - They may not achieve adequate bloodstream concentrations quickly enough to combat the rapid progression of inflammation and potential airway compromise. *Steroids* - While **corticosteroids** can help reduce inflammation, they are typically used as an adjunct to antibiotics, not as the primary treatment. - Steroids alone will not eradicate the bacterial infection responsible for epiglottitis. *Observation* - **Observation** is a dangerous approach for acute epiglottitis, as the condition can rapidly worsen and lead to **complete airway obstruction**. - Immediate medical and often airway management is necessary, not watchful waiting.

Q: Which of the following conditions is characterized by progressive hoarseness and a mass in the thyroid cartilage in an elderly patient?

Laryngeal carcinoma. ***Laryngeal carcinoma*** [1] - Progressive **hoarseness** and a **mass in the thyroid cartilage** are hallmark features of laryngeal carcinoma, especially in elderly patients [1,2]. - Typically presents with obstructive symptoms, which can compromise the airway and lead to swallowing difficulties. *Vocal cord paralysis* - Can lead to **hoarseness**, but is not typically associated with a visible **mass** in the thyroid cartilage. - Often results from **neurological disorders** or trauma rather than being a primary pathologic process. *Thyroid carcinoma* - While it can cause neck masses, it is more commonly associated with **lumps** in the thyroid gland rather than hoarseness and cartilage involvement. - Symptoms might include **thyroid enlargement** but typically do not localize to the larynx. *Thyroiditis* - Characterized by **inflammation** of the thyroid gland, which can cause tenderness and swelling, but not typically a mass in the **thyroid cartilage**. - Hoarseness can occur but is less common and not a defining feature of the condition. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 745-747. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Respiratory Tract Disease, pp. 314-315.

Q: A patient with a long-standing habit of smoking presents with hoarseness of voice. Which nerve is most likely to be affected?

Recurrent laryngeal nerve. ***Recurrent laryngeal nerve*** - **Hoarseness of voice** is the most common symptom of **recurrent laryngeal nerve (RLN) palsy**, as this nerve innervates most of the intrinsic muscles of the larynx responsible for vocal cord movement. - In a long-standing smoker, **lung cancer** (especially tumors in the apex of the lung या mediastinum) or metastatic disease can compress or invade the RLN, particularly on the **left side** due to its longer intrathoracic course [1]. *Vagus nerve* - The recurrent laryngeal nerve is a **branch of the vagus nerve (CN X)**; however, direct **vagus nerve** compression would also result in other symptoms such as dysphagia, dysarthria, or cardiac arrhythmias, which are not mentioned here. - While damage to the vagus nerve can lead to hoarseness, the **recurrent laryngeal nerve** is the more specific and direct cause of isolated hoarseness. *Phrenic nerve (controls diaphragm movement)* - The **phrenic nerve** primarily innervates the **diaphragm**, controlling its movement for respiration. - Damage to the phrenic nerve would cause **diaphragmatic paralysis** and **respiratory difficulties**, not hoarseness. *Hypoglossal nerve (innervates tongue muscles)* - The **hypoglossal nerve (CN XII)** controls the **movements of the tongue**. - Dysfunction of this nerve would lead to **dysarthria** (difficulty with speech articulation) and **tongue deviation or atrophy**, but not hoarseness.

Question 1

Most common benign lesion of vocal cord in pediatric age group is

Accepted Answer

Juvenile papillomatosis

Answer

Chondroma

Answer

Granular cell tumor

Answer

Solitary papilloma

Question 2

True about recurrent respiratory papillomatosis (multiple papillomatosis) -

Accepted Answer

HPV is causative agent

Answer

It is premalignant

Answer

Surgical excision is treatment of choice

Answer

It can occur at any age

Question 3

A high tracheostomy may be indicated in:

Accepted Answer

Severe bilateral vocal cord paralysis

Answer

Advanced carcinoma of the larynx

Answer

Chronic scleroma involving the larynx

Answer

Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)

Question 4

Inspiratory stridor is due to lesions of:

Accepted Answer

Subglottis

Answer

Supraglottis

Answer

Trachea

Answer

Bronchi

Question 5

A 45-year-old patient presents with persistent hoarseness for 3 months. Which finding on indirect laryngoscopy is most concerning for malignancy?

Accepted Answer

Unilateral cord paralysis

Answer

Reinke's edema

Answer

Bilateral polyps

Answer

Vocal cord nodules

Question 6

A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?

Accepted Answer

Direct laryngoscopy with biopsy

Answer

MRI of neck

Answer

CT scan of neck

Answer

Radiotherapy

Question 7

A 50-year-old male with a long smoking history presents with a 2-month history of hoarseness, ear pain, and hemoptysis. Laryngoscopy reveals a mass on the vocal cords, and a chest X-ray shows a suspicious nodule. What is the most likely diagnosis?

Accepted Answer

Laryngeal carcinoma

Answer

Tuberculosis

Answer

Pneumonia

Answer

Chronic bronchitis

Question 8

What is the treatment of choice for a patient with acute epiglottitis?

Accepted Answer

Intravenous antibiotics

Answer

Oral antibiotics

Answer

Steroids

Answer

Observation

Question 9

Which of the following conditions is characterized by progressive hoarseness and a mass in the thyroid cartilage in an elderly patient?

Accepted Answer

Laryngeal carcinoma

Answer

Thyroid carcinoma

Answer

Vocal cord paralysis

Answer

Thyroiditis

Question 10

A patient with a long-standing habit of smoking presents with hoarseness of voice. Which nerve is most likely to be affected?

Accepted Answer

Recurrent laryngeal nerve

Answer

Vagus nerve

Answer

Phrenic nerve (controls diaphragm movement)

Answer

Hypoglossal nerve (innervates tongue muscles)

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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