Diseases of the Larynx Practice Questions

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.

Q: A patient presents with a hoarse voice and cough for two weeks. Laryngoscopy reveals inflammation of the vocal cords. What is the most likely diagnosis?

Laryngitis. ***Correct: Laryngitis*** - The symptoms of a **hoarse voice** and **cough** for two weeks, coupled with **inflammation of the vocal cords** on laryngoscopy, are classic for laryngitis. - This condition is typically caused by viral infections, vocal cord overuse, or irritants, leading to swelling of the vocal cords. *Incorrect: Vocal cord paralysis* - While it causes **hoarseness**, **vocal cord paralysis** would present as a lack of movement or immobility of one or both vocal cords on laryngoscopy, not primarily inflammation. - It often results from nerve damage, surgery, or underlying neurological conditions, which are not suggested here. *Incorrect: Vocal cord nodules* - **Vocal cord nodules** (often called "singer's nodes") are bilateral, symmetrical lesions that develop on the vocal cords due to chronic voice abuse. - While they cause hoarseness, laryngoscopy would reveal distinct **nodular growths**, not general inflammation. *Incorrect: Reinke's edema* - **Reinke's edema** is characterized by diffuse gelatinous swelling of the superficial lamina propria of the vocal folds, usually associated with **chronic smoking**. - While it causes hoarseness, the laryngoscopic appearance would be a characteristic **edematous, fluid-filled appearance**, not simply inflammation.

Q: A patient presents with hoarseness and laryngoscopy reveals a warty, cauliflower-like growth on the vocal cord. Identify the most likely lesion.

Laryngeal papilloma. ***Laryngeal papilloma*** - **Hoarseness** and a **warty, cauliflower-like growth** on the vocal cord are classic descriptions of a laryngeal papilloma, often caused by **HPV infection**. - These lesions can be solitary or multiple, and while benign, they can recur and cause voice changes and respiratory obstruction. *Laryngeal malignancy* - While hoarseness is a common symptom of laryngeal malignancy, the description of a **"warty, cauliflower-like growth"** is more characteristic of a papilloma than most typical carcinomas, which might appear more ulcerative or infiltrative. - Malignancies are more commonly associated with risk factors like **smoking and alcohol use**, and often present with other symptoms like dysphagia or weight loss. *Tracheomalacia* - **Tracheomalacia** refers to softening of the tracheal cartilage, leading to airway collapse, typically causing stridor or respiratory distress. - It does not present as a **discrete growth** on the vocal cords but rather as a diffuse structural weakness of the trachea. *Reinke’s edema* - **Reinke's edema** (polypoid corditis) is characterized by a **gelatinous or fluid-filled swelling** of the vocal cords, usually associated with chronic irritation like smoking. - It presents as a swollen, boggy appearance of the vocal cords, not a warty or cauliflower-like growth.

Q: Inspiratory stridor is typically associated with which type of airway lesion?

Supraglottic lesions. ***Supraglottic lesions*** - **Inspiratory stridor** occurs due to turbulent airflow during inspiration, which is characteristic of **supraglottic obstruction** as the negative pressure during inspiration causes collapse of the lax tissues above the vocal cords [1]. - Common causes include **laryngomalacia**, epiglottitis, and foreign body aspiration in the pharynx or larynx above the vocal cords [1]. *Subglottic lesions* - **Subglottic lesions** typically cause **biphasic stridor** or expiratory stridor, as obstruction below the vocal cords affects both inspiratory and expiratory airflow. - Examples include **subglottic stenosis** or croup, where turbulent airflow occurs in both phases of respiration. *Tracheal lesions* - **Tracheal lesions** often lead to **biphasic inspiratory and expiratory stridor**, as the trachea is a rigid structure and obstruction affects airflow in both directions [1]. - Conditions like **tracheal stenosis** or tumors in the trachea cause constant airway narrowing [1]. *Bronchial lesions* - **Bronchial lesions** are more likely to cause **expiratory wheezing** or stridor, particularly if they are distal to the trachea. - Obstruction in the bronchi leads to air trapping and restricted outflow during expiration, producing a high-pitched whistling sound.

Question 1

Inspiratory stridor is due to lesions of:

Accepted Answer

Subglottis

Answer

Supraglottis

Answer

Trachea

Answer

Bronchi

Question 2

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 3

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 4

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 5

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

Accepted Answer

Intravenous antibiotics

Answer

Oral antibiotics

Answer

Steroids

Answer

Observation

Question 6

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 7

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)

Question 8

A patient presents with a hoarse voice and cough for two weeks. Laryngoscopy reveals inflammation of the vocal cords. What is the most likely diagnosis?

Accepted Answer

Laryngitis

Answer

Vocal cord paralysis

Answer

Vocal cord nodules

Answer

Reinke's edema

Question 9

A patient presents with hoarseness and laryngoscopy reveals a warty, cauliflower-like growth on the vocal cord. Identify the most likely lesion.

Accepted Answer

Laryngeal papilloma

Answer

Laryngeal malignancy

Answer

Tracheomalacia

Answer

Reinke’s edema

Question 10

Inspiratory stridor is typically associated with which type of airway lesion?

Accepted Answer

Supraglottic lesions

Answer

Subglottic lesions

Answer

Tracheal lesions

Answer

Bronchial lesions

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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