Diseases of the Larynx Practice Questions

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: 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.

Q: Turban epiglottis is seen in -

TB. ***TB*** - **Turban epiglottis** is a classic finding in **laryngeal tuberculosis**, characterized by a thickened, swollen, and often nodular epiglottis that resembles a turban. - This appearance results from granulomatous inflammation and edema of the laryngeal structures due to *Mycobacterium tuberculosis* infection. *Leprosy* - **Laryngeal involvement in leprosy** is rare but can cause mucosal thickening, nodules, and even stenosis. - While it can affect the larynx, the specific 'turban epiglottis' morphology is not characteristic of leprosy. *Laryngeal papilloma* - **Laryngeal papillomas** appear as wart-like growths, often cauliflower-like, on the vocal cords or other laryngeal surfaces. - They are caused by **Human Papillomavirus (HPV)** and do not typically present as a diffusely thickened or turban-shaped epiglottis. *Epiglottitis* - **Epiglottitis** presents with a rapidly swollen and cherry-red epiglottis, which can obstruct the airway. - This is an acute bacterial infection, usually by *Haemophilus influenzae type b*, and while the epiglottis is inflamed, the appearance is distinct from the chronic, nodular 'turban' described in TB.

Q: Thumb sign in lateral X-ray of the neck is seen in?

Epiglottitis. ***Epiglottitis*** - The **thumb sign** on a lateral neck X-ray is a classic finding in **acute epiglottitis**, caused by the severely swollen epiglottis. - This swelling can lead to severe **airway obstruction** due to its critical location. *Internal hemorrhage* - Internal hemorrhage in the neck might cause soft tissue swelling, but it typically does not produce the specific **"thumb sign" morphology** seen in epiglottitis. - Diagnosis relies more on **clinical signs of bleeding** and potentially imaging like CT scans to localize blood collections. *Saccular cyst* - A **saccular cyst** (or laryngocele) is a benign air-filled or fluid-filled sac - It would appear as a well-defined, often air-filled, or soft-tissue mass, not typically resembling the diffuse, inflamed "thumb" appearance of a swollen epiglottis. *Carcinoma of the epiglottis* - While a **carcinoma of the epiglottis** could cause epiglottic swelling or mass effect, it usually presents as a more irregular or focal mass rather than the uniform, bulbous swelling characteristic of the "thumb sign" in acute epiglottitis. - Carcinoma is also typically a chronic process, unlike the acute, rapidly progressing inflammation of epiglottitis.

Q: Mouse-nibbled vocal cords are seen in which condition?

Tuberculosis. ***Tuberculosis*** - **Laryngeal tuberculosis** can cause irregular, eroded, and edematous vocal cords, often described as having a **"mouse-nibbled"** appearance due to granular ulcerations [1]. - This characteristic appearance is due to the chronic inflammatory and destructive nature of **Mycobacterium tuberculosis** infection on the laryngeal mucosa [1]. *Leprosy* - **Laryngeal leprosy** can cause diffuse infiltration, nodules, and thickening of the vocal cords, but typically does not present with the specific **"mouse-nibbled"** appearance of erosions [2]. - The lesions tend to be more nodular and less ulcerative in nature compared to tuberculosis [2]. *Laryngeal papilloma* - **Laryngeal papillomas** are benign tumors that present as wart-like growths on the vocal cords, often appearing as **mulberry-like** or **cauliflower-like** lesions [1]. - They do not typically cause the irregular, eroded, or "mouse-nibbled" pattern associated with tuberculosis. *Epiglottitis* - **Epiglottitis** is an acute inflammation of the epiglottis, primarily characterized by a **cherry-red, swollen epiglottis** and surrounding structures [1]. - While it can cause airway obstruction, it does not involve the characteristic erosions or "mouse-nibbled" appearance of the vocal cords [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 745-746. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Infectious Diseases, pp. 385-386.

Question 1

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 2

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 3

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 4

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 5

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 6

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 7

Biphasic stridor is characteristically seen in:

Accepted Answer

Laryngeal foreign body

Answer

Bronchial foreign body

Answer

None of the options

Answer

Tracheal foreign body

Question 8

Turban epiglottis is seen in -

Accepted Answer

TB

Answer

Epiglottitis

Answer

Laryngeal papilloma

Answer

Leprosy

Question 9

Thumb sign in lateral X-ray of the neck is seen in?

Accepted Answer

Epiglottitis

Answer

Internal hemorrhage

Answer

Saccular cyst

Answer

Carcinoma of the epiglottis

Question 10

Mouse-nibbled vocal cords are seen in which condition?

Accepted Answer

Tuberculosis

Answer

Leprosy

Answer

Laryngeal papilloma

Answer

Epiglottitis

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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