Diseases of the Larynx Practice Questions

Q: Reinke's layer is seen in:

Vocal cord. ***Vocal cord*** - **Reinke's space**, also known as Reinke's layer, is the superficial layer of the **lamina propria** of the vocal cord. - This layer is crucial for the **vibration of the vocal folds**, which is essential for sound production. *Tympanic membrane* - The **tympanic membrane**, or eardrum, is a thin membrane that separates the external ear from the middle ear [1]. [2]. - It vibrates in response to **sound waves** and transmits these vibrations to the ossicles, playing a role in hearing, not vocalization [1], [2]. *Cochlea* - The **cochlea** is a spiral-shaped cavity in the inner ear involved in the sense of hearing [2]. - It contains the **organ of Corti**, which converts sound vibrations into nerve impulses but has no connection to vocal cord anatomy [2]. *Reissner's membrane* - **Reissner's membrane** (vestibular membrane) is a thin membrane that separates the scala vestibuli from the scala media within the cochlea. - Its primary function is to maintain the **composition of the endolymph** in the scala media, and it is part of the auditory system, not the larynx.

Q: What condition is characterized by a mouse-nibbled appearance of the vocal cord?

Laryngeal tuberculosis. ***Laryngeal tuberculosis*** - A **mouse-nibbled appearance** of the vocal cord, characterized by **irregular, ragged edges**, is a classic endoscopic finding in laryngeal tuberculosis. - This presentation results from **granulomatous inflammation** and **ulceration** of the vocal cord tissue. *Vocal cord nodules* - Vocal cord nodules typically present as **bilateral, symmetrical swellings** on the free edge of the vocal cords, often described as "singer's nodules." - They tend to be **smooth and rounded**, not "mouse-nibbled." *Vocal cord paralysis* - Vocal cord paralysis involves an **absence or impairment of vocal cord movement**, leading to an altered glottic closure and voice change. - The vocal cord itself usually appears **structurally normal** in terms of its surface and edges, distinguishing it from an erosive process. *Laryngeal carcinoma* - Laryngeal carcinoma can present with various appearances, including **ulcerations, exophytic masses, or infiltrative lesions**. - While it can cause irregular surfaces, the specific "mouse-nibbled" description is more pathognomonic for **tuberculous laryngitis** due to its characteristic pattern of superficial erosion.

Q: All of the following are seen in superior laryngeal nerve palsy except:

Stridor. ***Stridor*** - **Superior laryngeal nerve palsy** primarily affects the **cricothyroid muscle** (external branch) and sensation above the vocal cords (internal branch). - Stridor typically results from severe **airway obstruction**, which is not a direct consequence of superior laryngeal nerve palsy as the **vocal cords** are not paralyzed open or closed to cause obstruction. *Aspiration* - The **internal branch of the superior laryngeal nerve** provides sensory innervation to the **supraglottic larynx**. - Loss of sensation in this region can impair the protective **cough reflex**, leading to an increased risk of aspiration. *Bowed vocal cords* - **Palsy of the cricothyroid muscle**, innervated by the **external branch of the superior laryngeal nerve**, causes a loss of tension in the vocal cord. - This lack of tension can result in a characteristically **bowed appearance** of the affected vocal cord during phonation. *Loss of pitch* - The **cricothyroid muscle** is responsible for tensing and elongating the vocal cords, which is crucial for **raising vocal pitch**. - Paralysis of this muscle due to **superior laryngeal nerve palsy** directly impairs the ability to achieve higher pitches, leading to a **monotone voice** or loss of pitch.

Q: A 50-year-old male chronic smoker complains of hoarseness of voice for the past 4 months. Microlaryngoscopic biopsy shows it to be keratosis of the larynx. All are suggested treatment modalities for this condition, except:

Partial laryngectomy. ***Partial laryngectomy*** - **Partial laryngectomy** is a surgical procedure typically reserved for **laryngeal cancer** that has invaded deeper tissues or is extensive. - Laryngeal keratosis, even with atypia, is a **premalignant lesion** and does not usually warrant such an aggressive surgical intervention as a primary treatment. *Stop smoking* - **Cigarette smoking** is a major causative factor for laryngeal keratosis and its progression to dysplasia or carcinoma. - **Cessation of smoking** can often lead to regression of the keratosis and is a crucial first step in management. *Laser vaporization* - **Laser vaporization** using CO2 laser is an effective method for precise removal of the keratotic lesions. - It allows for **accurate tissue ablation** while preserving surrounding healthy tissue and maintaining vocal function. *Stripping of vocal cord* - **Vocal cord stripping** is a common surgical technique used to remove superficial lesions like keratosis from the vocal cords. - This procedure involves **peeling off the superficial layer** of the vocal cord while aiming to preserve the deeper structures essential for voice quality.

Q: Which of the following statements about laryngomalacia is true?

It typically presents with inspiratory stridor.. ***It typically presents with inspiratory stridor.*** - **Laryngomalacia** is the most common cause of **inspiratory stridor** in infants, usually presenting within the first few weeks of life due to collapse of supraglottic structures during inspiration. - The stridor is characteristically **worse when crying, feeding, or lying supine**, and often improves when the infant is prone. *It is characterized by an omega-shaped epiglottis.* - While an **omega-shaped epiglottis** can be a feature seen in laryngomalacia, it is not the sole or defining characteristic and is not universally present. - The primary characteristic is the **collapse of the supraglottic structures** (arytenoids, aryepiglottic folds, and epiglottis) into the laryngeal inlet upon inspiration. *It requires immediate surgical intervention.* - The vast majority of **laryngomalacia cases are mild to moderate** and resolve spontaneously by 12-18 months of age, requiring only conservative management. - **Surgical intervention** (supraglottoplasty) is reserved for severe cases with significant feeding difficulties, failure to thrive, severe airway obstruction, or apneic episodes. *It always requires surgical intervention in newborns.* - As mentioned, **most cases are self-limiting** and do not require surgery, especially in newborns. - Surgical intervention is only considered when there are **severe symptoms** impacting the infant's health and development.

Q: What is the most common cause of left-sided vocal cord palsy?

Vocal cord surgery complication. ***Vocal cord surgery complication*** - Damage to the **recurrent laryngeal nerve** during surgeries like thyroidectomy or parathyroidectomy is a common iatrogenic cause of vocal cord palsy [1]. - While other conditions can cause left-sided palsy, surgical trauma is a very frequent and direct cause due to the nerve's proximity [1]. *Left hilar bronchial carcinoma* - A left hilar bronchial carcinoma can compress or invade the **left recurrent laryngeal nerve**, leading to left vocal cord palsy. - This is a significant cause, but iatrogenic injury is often more prevalent overall. *Mitral stenosis* - Severe **mitral stenosis** can lead to an enlarged left atrium, which may compress the left recurrent laryngeal nerve, causing vocal cord palsy (Ortner's syndrome). - This is a less common cause compared to other etiologies, and often seen in advanced cardiac disease. *Thyroid cancer* - **Thyroid cancer** can invade the recurrent laryngeal nerve directly, leading to vocal cord paralysis [1]. - While a direct cause, its incidence as 'the most common cause' is often less than iatrogenic injury by surgeons for benign or malignant thyroid conditions [1].

Q: According to the European Laryngological Society, how is subligamental cordectomy classified within their classification system?

Type II (Subepithelial cordectomy). ***Type II (Subepithelial cordectomy)*** - According to the **European Laryngological Society (ELS) classification**, **Type II cordectomy** is specifically defined as **subligamental cordectomy**. - This procedure removes the **epithelium, Reinke's space, and vocal ligament**, but remains **superficial to the vocalis muscle**. - Type II is the correct classification for subligamental procedures, as it extends through the ligament but does not penetrate the underlying muscle layer. *Type III (Transmuscular cordectomy)* - **Type III cordectomy** extends **deeper than Type II**, involving excision that includes the **vocalis muscle**. - This is a **transmuscular** resection that goes beyond the ligament into the muscle layer, making it more extensive than a subligamental cordectomy. - The key differentiating feature is that Type III penetrates the vocalis muscle, whereas subligamental (Type II) stops at the ligament level. *Type IV (Total cordectomy)* - **Type IV cordectomy** involves **complete removal** of the entire vocal cord from the **vocal process to the anterior commissure**. - This is the most extensive single-cord resection, removing all layers including epithelium, ligament, and the entire vocalis muscle. - This far exceeds the depth and extent of a subligamental cordectomy. *Type Va (Subligamental cordectomy)* - In the ELS classification, **Type V cordectomies** are **extended cordectomies** with various subclassifications (Va, Vb, Vc, Vd). - **Type Va** specifically refers to **cordectomy with contralateral arytenoid**, not subligamental cordectomy. - The term "subligamental" in this option is a misnomer; the ELS system uses **Type II** for subligamental procedures, not Type Va.

Q: What is the expected voice quality in a patient with bilateral abductor paralysis of the larynx?

Preserved voice quality (Normal voice). ***Preserved voice quality (Normal voice)*** - In **bilateral abductor paralysis**, the vocal cords are fixed in or near the midline, primarily affecting the **airway** and causing inspiratory stridor. - While breathing is severely compromised, the **vocal cords can still adduct sufficiently for phonation**, meaning the voice quality often remains largely normal, albeit with possibly reduced intensity. *High-pitched voice (Puberphonia)* - **Puberphonia** is a functional voice disorder characterized by the persistent use of a high-pitched voice after puberty, despite a normal mature larynx. - It is not directly related to laryngeal paralysis but rather a **phonatory habit or psychological cause**. *Vocal fatigue (Phonasthenia)* - **Vocal fatigue** is a symptom often associated with vocal misuse, overuse, or certain laryngeal pathologies causing inefficient vocal production. - While a patient with laryngeal paralysis might vocalize less due to respiratory distress, the paralysis itself does not directly cause vocal fatigue as a primary voice quality. *Strained voice (Dysphonia plicae ventricularis)* - **Dysphonia plicae ventricularis**, or **ventricular dysphonia**, occurs when the false vocal cords (ventricular folds) vibrate during phonation instead of or in addition to the true vocal cords, resulting in a low-pitched, harsh, or strained voice. - This condition is not a direct consequence of bilateral abductor paralysis, which primarily impacts true vocal cord movement and airway patency.

Q: What is the primary cause of stridor?

Obstruction of the airway at the level of the vocal cords. ***Obstruction of the airway at the level of the vocal cords*** - Stridor is a **high-pitched** breath sound resulting from turbulent airflow through a **narrowed upper airway**. - **Glottic obstruction** (at the vocal cord level) is the **classic cause** of stridor, producing the characteristic inspiratory sound from conditions like **laryngospasm**, **vocal cord paralysis**, or **laryngeal foreign bodies**. - The **vocal cords** represent the narrowest point of the adult upper airway, making this level particularly prone to producing audible turbulent flow. *Obstruction of the airway below the vocal cords* - Obstruction in the **intrathoracic trachea** or **bronchi** typically causes **wheezing** rather than stridor. - However, **subglottic obstruction** (immediately below the vocal cords but still extrathoracic) can produce stridor, especially in conditions like **croup**. - The key distinction is whether the obstruction is in the extrathoracic (stridor) or intrathoracic (wheeze) airway. *Obstruction of the airway above the vocal cords* - **Supraglottic obstruction** (epiglottitis, retropharyngeal abscess) can also cause stridor, though the quality may differ slightly. - While this can produce stridor, the **most classic** presentation occurs at the glottic (vocal cord) level due to the critical narrowing at this point. - Severe pharyngeal obstruction may produce **stertor** (low-pitched snoring), but acute supraglottic pathology typically causes stridor. *Obstruction of the airway above the trachea* - This is a **non-specific term** encompassing both supraglottic and glottic regions. - While technically correct that stridor occurs "above the trachea," this lacks the anatomical precision needed to identify the **classic level** of obstruction at the vocal cords.

Q: Biphasic stridor is characteristically seen in:

Laryngeal foreign body. ***Laryngeal foreign body*** - **Biphasic stridor** is the hallmark finding in laryngeal/subglottic foreign bodies as they obstruct airflow during **both inspiration and expiration**. - The obstruction at the **glottic or subglottic level** causes turbulent airflow in both phases of respiration, producing the characteristic biphasic quality. - Often accompanied by **hoarseness**, **croupy cough**, **dysphagia**, and **respiratory distress**. *Tracheal foreign body* - Tracheal foreign bodies typically produce **expiratory stridor** or **monophonic wheeze** rather than biphasic stridor. - May present with **Holzknecht's sign** (slapping sound with respiration), **palpable thud**, and **audible slap**. - **Cough** and **dyspnea** are more prominent than stridor. *Bronchial foreign body* - Bronchial foreign bodies cause **wheezing**, **diminished breath sounds** on the affected side, and **obstructive emphysema**. - Located beyond the carina, they rarely cause stridor as stridor originates from **laryngotracheal** obstruction. - May present with **persistent cough**, **recurrent pneumonia**, or **atelectasis**. *None of the options* - This is incorrect as **laryngeal foreign body** is the classic cause of biphasic stridor in medical literature. - **Glottic and subglottic obstructions** characteristically produce biphasic stridor affecting both respiratory phases.

Question 1

Reinke's layer is seen in:

Accepted Answer

Vocal cord

Answer

Tympanic membrane

Answer

Cochlea

Answer

Reissner's membrane

Question 2

What condition is characterized by a mouse-nibbled appearance of the vocal cord?

Accepted Answer

Laryngeal tuberculosis

Answer

Vocal cord nodules

Answer

Vocal cord paralysis

Answer

Laryngeal carcinoma

Question 3

All of the following are seen in superior laryngeal nerve palsy except:

Accepted Answer

Stridor

Answer

Bowed vocal cords

Answer

Loss of pitch

Answer

Aspiration

Question 4

A 50-year-old male chronic smoker complains of hoarseness of voice for the past 4 months. Microlaryngoscopic biopsy shows it to be keratosis of the larynx. All are suggested treatment modalities for this condition, except:

Accepted Answer

Partial laryngectomy

Answer

Stop smoking

Answer

Stripping of vocal cord

Answer

Laser vaporization

Question 5

Which of the following statements about laryngomalacia is true?

Accepted Answer

It typically presents with inspiratory stridor.

Answer

It is characterized by an omega-shaped epiglottis.

Answer

It requires immediate surgical intervention.

Answer

It always requires surgical intervention in newborns.

Question 6

What is the most common cause of left-sided vocal cord palsy?

Accepted Answer

Vocal cord surgery complication

Answer

Mitral stenosis

Answer

Thyroid cancer

Answer

Left hilar bronchial carcinoma

Question 7

According to the European Laryngological Society, how is subligamental cordectomy classified within their classification system?

Accepted Answer

Type II (Subepithelial cordectomy)

Answer

Type Va (Subligamental cordectomy)

Answer

Type IV (Total cordectomy)

Answer

Type III (Transmuscular cordectomy)

Question 8

What is the expected voice quality in a patient with bilateral abductor paralysis of the larynx?

Accepted Answer

Preserved voice quality (Normal voice)

Answer

High-pitched voice (Puberphonia)

Answer

Vocal fatigue (Phonasthenia)

Answer

Strained voice (Dysphonia plicae ventricularis)

Question 9

What is the primary cause of stridor?

Accepted Answer

Obstruction of the airway at the level of the vocal cords

Answer

Obstruction of the airway below the vocal cords

Answer

Obstruction of the airway above the vocal cords

Answer

Obstruction of the airway above the trachea

Question 10

Biphasic stridor is characteristically seen in:

Accepted Answer

Laryngeal foreign body

Answer

Bronchial foreign body

Answer

None of the options

Answer

Tracheal foreign body

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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