Diseases of the Larynx — MCQs

A 28-year-old male singer/songwriter has experienced hoarseness for the past year, with a progressive decline in voice quality. He has been playing at clubs nightly for the past 3 years to avoid homelessness and was advised to quit smoking on previous visits. Physical examination reveals no fever, palpable head and neck masses, cough, or significant sputum production. What is the most likely diagnosis causing these findings?

Q44Medium

Which of the following is the most common cause of vocal cord palsy?

Q45Medium

Which of the following is true regarding paralysis of the recurrent laryngeal nerve?

Q46Easy

What is an indication for tracheostomy?

Q47Medium

An alcoholic presented with globus sensation in throat, cough, and hoarseness. Larynx examination shows a pseudosulcus. A pseudosulcus is seen in which of the following conditions?

Q48Easy

All of the following are true regarding tracheostomy tube except:

Q49Medium

What is the best treatment for laryngeal cancer involving the anterior commissure?

Q50Medium

An elderly male presents with hoarseness, cough, dysphagia, and a foreign body sensation in the throat. A laryngocele is suspected. From which anatomical structure does a laryngocele arise from herniation?

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 41: Which of the following are indications for tracheostomy?

A. Flail chest
B. Head injury
C. Tetanus
D. All of the above (Correct Answer)

Explanation: Tracheostomy is a surgical procedure performed to create an airway, bypass upper airway obstruction, or facilitate long-term mechanical ventilation. The correct answer is **All of the above** because each condition listed represents a specific category of tracheostomy indications. ### **Explanation of Indications:** 1. **Flail Chest (Option A):** In severe chest wall injuries, paradoxical respiration leads to respiratory failure. Tracheostomy is indicated to **reduce anatomical dead space** (by approx. 30-50%), decrease the work of breathing, and facilitate the removal of tracheobronchial secretions. 2. **Head Injury (Option B):** Patients with severe head injuries often have a depressed Glasgow Coma Scale (GCS) score. Tracheostomy is performed for **protection of the airway** against aspiration (due to loss of protective reflexes) and to provide a stable route for prolonged mechanical ventilation. 3. **Tetanus (Option C):** Severe tetanus causes generalized muscle spasms, including **laryngospasm** and spasms of the respiratory muscles. Tracheostomy is life-saving here to maintain a patent airway and manage secretions during prolonged sedation and neuromuscular blockade. ### **High-Yield Clinical Pearls for NEET-PG:** * **Dead Space Reduction:** Tracheostomy reduces anatomical dead space by about **70-100 ml**, which is critical in patients with limited respiratory reserve (like Flail Chest). * **The "Rule of 2" (Traditional):** If a patient requires intubation for more than 2 weeks, a tracheostomy is usually considered to prevent subglottic stenosis. * **Emergency Procedure of Choice:** In an acute "cannot intubate, cannot ventilate" scenario, **Cricothyroidotomy** is the preferred emergency procedure, not a formal tracheostomy. * **Level of Incision:** A routine tracheostomy is performed by making an opening in the **2nd, 3rd, or 4th tracheal rings**. Avoid the 1st ring to prevent subglottic stenosis.

Question 42: Stridor is caused by all except:

A. Hypocalcemia
B. Asthma (Correct Answer)
C. Epiglottitis
D. Laryngeal tumor

Explanation: **Explanation:** The core concept in differentiating respiratory sounds lies in the **anatomical site of obstruction**. **Stridor** is a high-pitched, predominantly inspiratory sound caused by turbulent airflow through a partially obstructed **upper airway** (at or above the level of the larynx/trachea). In contrast, **Wheezing** is a continuous, musical, predominantly expiratory sound caused by narrowing of the **lower airways** (bronchi and bronchioles). * **Why Asthma is the correct answer:** Asthma is a chronic inflammatory disease of the lower airways characterized by reversible bronchoconstriction. Since the pathology is distal to the trachea, it presents with **wheezing**, not stridor. * **Why other options are incorrect:** * **Hypocalcemia:** Low calcium levels lead to neuromuscular irritability, which can cause **Laryngospasm**. This acute narrowing of the glottis results in inspiratory stridor. * **Epiglottitis:** This is a supraglottic infection causing massive edema of the epiglottis. It is a classic cause of acute inspiratory stridor (often accompanied by the "tripod position" and "thumb sign" on X-ray). * **Laryngeal Tumor:** Any growth (benign or malignant) within the larynx narrows the airway lumen, leading to progressive chronic stridor. **High-Yield Clinical Pearls for NEET-PG:** 1. **Inspiratory Stridor:** Indicates a lesion at or above the vocal cords (Supraglottic/Glottic). 2. **Biphasic Stridor:** Indicates a subglottic or tracheal lesion. 3. **Expiratory Stridor:** Indicates a bronchial lesion (often overlaps with wheezing). 4. **Laryngomalacia:** The most common cause of congenital inspiratory stridor in infants; it characteristically increases when the child is supine or crying.

Question 43: A 28-year-old male singer/songwriter has experienced hoarseness for the past year, with a progressive decline in voice quality. He has been playing at clubs nightly for the past 3 years to avoid homelessness and was advised to quit smoking on previous visits. Physical examination reveals no fever, palpable head and neck masses, cough, or significant sputum production. What is the most likely diagnosis causing these findings?

A. Croup
B. Epiglottitis
C. Reactive nodule (Correct Answer)
D. Squamous cell carcinoma

Explanation: ### Explanation **Correct Option: C. Reactive nodule (Vocal Cord Nodule)** The patient’s clinical profile—a young professional singer with a long-standing history of vocal abuse (nightly performances) and progressive hoarseness—is classic for **Vocal Cord Nodules** (also known as Singer’s or Screamer’s nodules). * **Pathophysiology:** Chronic vocal abuse causes mechanical trauma to the vocal folds, leading to edema and fibrosis. * **Location:** They are typically **bilateral and symmetrical**, occurring at the junction of the **anterior 1/3 and posterior 2/3** of the vocal cords (the point of maximum vibratory amplitude). * **Clinical Presentation:** Chronic hoarseness (dysphonia) and voice fatigue without systemic symptoms like fever or weight loss. **Why other options are incorrect:** * **A & B (Croup/Epiglottitis):** These are acute inflammatory/infectious conditions. They present with rapid onset, fever, inspiratory stridor, and respiratory distress, typically in children. This patient has a chronic (1-year) course. * **D (Squamous Cell Carcinoma):** While smoking is a risk factor, SCC usually presents in older patients (50+ years) and is often associated with "red flag" symptoms like weight loss, hemoptysis, or cervical lymphadenopathy, which are absent here. --- ### High-Yield Pearls for NEET-PG * **Site of Nodule:** Junction of anterior 1/3 and posterior 2/3 of the vocal cord. * **Treatment:** The primary treatment is **Voice Therapy** (conservative). Surgery (Microlaryngeal surgery) is reserved only for large, recalcitrant fibrotic nodules. * **Vocal Polyp:** Unlike nodules, polyps are usually **unilateral** and often follow a single episode of acute vocal trauma (screaming). * **Reinke’s Edema:** Bilateral diffuse swelling of the vocal cords seen almost exclusively in **heavy smokers**.

Question 44: Which of the following is the most common cause of vocal cord palsy?

A. Trauma
B. Malignancy
C. Inflammatory causes
D. Surgical causes (Correct Answer)

Explanation: **Explanation:** The etiology of vocal cord palsy has shifted over the decades. While idiopathic causes were historically common, **surgical trauma** is now recognized as the **most common cause** of both unilateral and bilateral vocal cord palsy. 1. **Why Surgical Causes are Correct:** Iatrogenic injury during surgery is the leading cause. The most frequent culprit is **Thyroidectomy** (due to injury to the Recurrent Laryngeal Nerve). Other significant surgical causes include parathyroid surgery, esophageal surgery, and cardiothoracic procedures (especially on the left side due to the longer course of the left RLN around the aortic arch). 2. **Why other options are incorrect:** * **Malignancy:** This is the second most common cause. Bronchogenic carcinoma (especially on the left), esophageal cancer, and thyroid malignancies can infiltrate the nerve, but statistically, they follow surgical trauma. * **Trauma:** Non-surgical trauma (e.g., blunt neck trauma or penetrating injuries) is a recognized cause but occurs much less frequently than controlled surgical interventions. * **Inflammatory causes:** Conditions like neuritis (viral) or tuberculosis are relatively rare causes compared to the mechanical disruption seen in surgery. **High-Yield Clinical Pearls for NEET-PG:** * **Left vs. Right:** Left vocal cord palsy is more common than right because the **Left Recurrent Laryngeal Nerve** has a longer intrathoracic course, making it vulnerable to mediastinal pathologies (e.g., Ortner’s Syndrome/Left atrial enlargement). * **Semon’s Law:** In progressive lesions of the RLN, abductor fibers are injured first; thus, the cord initially moves to a midline position. * **Most common non-surgical cause:** Historically, **Idiopathic** was the top answer, but in modern exams, **Malignancy** (specifically Lung CA) is the most common non-surgical cause.

Question 45: Which of the following is true regarding paralysis of the recurrent laryngeal nerve?

A. It is more common on the left side. (Correct Answer)
B. It is idiopathic in 50% of cases.
C. The vocal cord will lie in a lateral position.
D. Speech therapy is the primary treatment.

Explanation: **Explanation:** **1. Why Option A is correct:** Recurrent Laryngeal Nerve (RLN) paralysis is significantly more common on the **left side** due to its longer and more convoluted anatomical course. While the right RLN loops around the subclavian artery in the neck, the left RLN descends into the thorax, loops around the **arch of the aorta**, and ascends back to the larynx. This extended intrathoracic course makes the left nerve more vulnerable to compression or injury from mediastinal pathologies (e.g., lung malignancy, aortic aneurysm, or esophageal tumors). **2. Why the other options are incorrect:** * **Option B:** While many cases are idiopathic, the most common cause of RLN paralysis is **surgical trauma** (especially thyroidectomy). Idiopathic causes account for approximately 20–30% of cases, not 50%. * **Option C:** In isolated RLN paralysis, the vocal cord typically lies in the **paramedian position**. This is explained by **Semon’s Law**, which states that in progressive lesions, abductor fibers are injured before adductor fibers. The cord only assumes a lateral position in combined paralysis (RLN + Superior Laryngeal Nerve). * **Option D:** Treatment depends on the etiology and whether the paralysis is unilateral or bilateral. For unilateral paralysis, the primary goal is often medialization (e.g., Type I Thyroplasty) if compensation doesn't occur. Speech therapy is an adjunct, not the definitive primary treatment for the nerve injury itself. **High-Yield Clinical Pearls for NEET-PG:** * **Semon’s Law:** Abductors (Posterior Cricoarytenoid) are more vulnerable than adductors. * **Most common cause:** Surgical trauma (Thyroidectomy). * **Most common non-traumatic cause:** Bronchogenic carcinoma (Left side). * **Ortner’s Syndrome:** Left RLN palsy caused by cardiovascular disorders (e.g., mitral stenosis leading to left atrial enlargement).

Question 46: What is an indication for tracheostomy?

A. Vocal cord replacement
B. Pharynx replacement
C. Tracheomalacia
D. Foreign body obstructing the airway (Correct Answer)

Explanation: **Explanation:** Tracheostomy is a surgical procedure that creates an opening in the anterior wall of the trachea to establish an alternative airway. The primary indications are categorized into **respiratory obstruction**, protection of the tracheobronchial tree, and assisted ventilation. **Why Option D is Correct:** A **foreign body obstructing the airway** (especially if lodged in the larynx or upper trachea) constitutes an acute respiratory emergency. When the airway is blocked above the level of the trachea and cannot be cleared by conservative methods (like the Heimlich maneuver or bronchoscopy), a tracheostomy (or emergency cricothyroidotomy) is indicated to bypass the obstruction and restore ventilation. **Analysis of Incorrect Options:** * **Options A & B (Vocal cord/Pharynx replacement):** These are reconstructive surgeries. While a tracheostomy might be performed *during* these major head and neck surgeries to maintain a safe airway post-operatively, the "replacement" itself is not an indication for the procedure. * **Option C (Tracheomalacia):** This involves the weakening of tracheal cartilage. While severe cases may occasionally require a tracheostomy to provide a stent or long-term ventilation, it is generally managed with CPAP or surgical pexy. In the context of this question, an acute mechanical obstruction (Option D) is a more classic, absolute indication. **High-Yield Clinical Pearls for NEET-PG:** * **Level of Tracheostomy:** Usually performed between the **2nd and 3rd or 3rd and 4th tracheal rings**. * **Emergency Airway:** In a "cannot intubate, cannot ventilate" scenario, **Cricothyroidotomy** is the fastest emergency procedure, later converted to a formal tracheostomy. * **Most Common Complication:** The most common immediate complication is **hemorrhage**; the most common late complication is **tracheal stenosis**. * **Indication for Prolonged Intubation:** If a patient requires mechanical ventilation for more than **7–14 days**, a tracheostomy is indicated to prevent subglottic stenosis.

Question 47: An alcoholic presented with globus sensation in throat, cough, and hoarseness. Larynx examination shows a pseudosulcus. A pseudosulcus is seen in which of the following conditions?

A. Vocal abuse
B. Tuberculosis
C. Laryngopharyngeal reflux (Correct Answer)
D. Chronic steroid use

Explanation: **Explanation:** The correct answer is **Laryngopharyngeal Reflux (LPR)**. **Understanding the Concept:** LPR occurs when gastric contents (acid and pepsin) reflux into the larynx and pharynx. Unlike GERD, LPR often presents without heartburn but with "silent" symptoms like globus sensation, chronic cough, and hoarseness. **Pseudosulcus vocalis** is a classic physical finding in LPR; it refers to subglottic edema extending from the anterior commissure to the posterior larynx, creating a "groove-like" appearance along the entire length of the vocal cord. This is distinct from *Sulcus Vocalis*, which is a true structural invagination of the epithelium. **Analysis of Incorrect Options:** * **Vocal abuse:** Typically leads to **Vocal Nodules** (bilateral, junction of anterior 1/3 and posterior 2/3) or vocal polyps, not subglottic edema. * **Tuberculosis:** Laryngeal TB usually presents with a "moth-eaten" appearance of the epiglottis, ulceration, or granulation tissue, often in the posterior commissure. * **Chronic steroid use:** This is a risk factor for **Laryngeal Candidiasis** (white plaques) or mucosal atrophy, but it does not cause a pseudosulcus. **NEET-PG High-Yield Pearls:** * **Reflux Finding Score (RFS):** Used to grade LPR severity; pseudosulcus is a key component. * **Posterior Laryngitis:** LPR characteristically causes erythema and pachydermia (thickening) of the interarytenoid area. * **Management:** Lifestyle modifications (avoiding alcohol/caffeine) and aggressive Proton Pump Inhibitor (PPI) therapy for 3–6 months.

Question 48: All of the following are true regarding tracheostomy tube except:

A. Double lumen tube
B. Made of titanium silver alloy
C. Cuffed tube prevents aspiration of pharyngeal secretions
D. Ideally should be changed every 3rd day (Correct Answer)

Explanation: ### Explanation The correct answer is **D**, as the recommendation to change a tracheostomy tube every 3rd day is incorrect and clinically unnecessary. **1. Why Option D is the Correct Answer (The False Statement):** A tracheostomy tube should **not** be changed every 3rd day. The first tube change is typically performed by a surgeon **5 to 7 days** after the procedure. This delay ensures that the **mature tract (stoma)** has formed between the skin and the trachea. Changing it too early (e.g., day 3) increases the risk of the tract collapsing, leading to accidental "false passage" insertion into the pre-tracheal space, which is a surgical emergency. Once the tract is mature, PVC tubes are usually changed every 1–4 weeks, while metal tubes can stay longer with regular inner cannula cleaning. **2. Analysis of Other Options:** * **A. Double lumen tube:** Most modern tracheostomy tubes (like the Jackson’s or Fuller’s) consist of an **outer cannula** (stays in place) and an **inner cannula** (removable for cleaning). This prevents lumen obstruction by dried mucus. * **B. Made of titanium silver alloy:** Metal tubes, specifically the **Fuller’s tube**, are traditionally made of a silver-titanium alloy. Silver has inherent antibacterial properties and is non-irritating to the tissues. * **C. Cuffed tube prevents aspiration:** A cuffed tube (usually high-volume, low-pressure) provides a seal against the tracheal wall. This is essential in patients with impaired laryngeal reflexes to prevent the aspiration of saliva and gastric contents into the lower airway. **Clinical Pearls for NEET-PG:** * **Safe Triangle of Jackson:** The anatomical area for safe tracheostomy (bounded by the sternocleidomastoid muscles and the thyroid notch). * **Level of Incision:** Ideally performed at the level of the **2nd and 3rd (or 3rd and 4th) tracheal rings**. * **Emergency Procedure:** If a patient develops sudden respiratory distress after a tube change, the first step is to check for tube displacement or a mucus plug. * **Fenestrated Tubes:** Used for **decannulation weaning** and to allow the patient to speak by directing air through the vocal cords.

Question 49: What is the best treatment for laryngeal cancer involving the anterior commissure?

A. Laryngectomy (Correct Answer)
B. Radiotherapy followed by surgery
C. Chemotherapy
D. None of the above

Explanation: **Explanation:** The **Anterior Commissure (AC)** is a critical anatomical site in the larynx where the vocal cords meet anteriorly. It is considered a "weak spot" for cancer management due to the absence of a perichondrium at the attachment of the Broyle’s ligament. **1. Why Laryngectomy is the Correct Answer:** Tumors involving the anterior commissure have a high propensity for **early cartilage invasion** (thyroid cartilage) and spread into the pre-epiglottic space. Because the AC is poorly vascularized and often involves the underlying cartilage, it is notoriously **radioresistant**. Surgical intervention—specifically a Vertical Partial Laryngectomy or Total Laryngectomy (depending on the extent)—is preferred to ensure complete oncological clearance. In the context of NEET-PG, when AC involvement is specified, surgery (Laryngectomy) is the gold standard over radiation. **2. Why other options are incorrect:** * **Radiotherapy (Option B):** While RT is excellent for early T1 glottic cancers, it has a high failure rate in AC involvement. The lack of vascularity in this region leads to poor oxygenation of tissues, making the tumor cells less sensitive to radiation. * **Chemotherapy (Option C):** Chemotherapy is primarily used as part of "Organ Preservation Protocols" (induction) or for palliative care in advanced laryngeal cancer. It is not a definitive primary treatment for localized AC involvement. **Clinical Pearls for NEET-PG:** * **Broyle’s Ligament:** The structure that attaches the vocal cords to the thyroid cartilage; it lacks a perichondrium, acting as a pathway for tumor spread. * **Hostile Site:** The AC is often called a "blind spot" for clinicians and a "difficult zone" for radiotherapy. * **Staging:** Involvement of the AC often upgrades the complexity of the surgery required to maintain a safe margin.

Question 50: An elderly male presents with hoarseness, cough, dysphagia, and a foreign body sensation in the throat. A laryngocele is suspected. From which anatomical structure does a laryngocele arise from herniation?

A. Cricothyroid membrane
B. Thyrohyoid membrane (Correct Answer)
C. Laryngeal fold
D. None of the above

Explanation: ### Explanation **1. Why Option B (Thyrohyoid membrane) is correct:** A laryngocele is an abnormal cystic dilatation of the **laryngeal saccule** (an upward extension of the laryngeal ventricle). When the saccule distends with air, it can remain internal or extend superiorly. To become an **external or mixed laryngocele**, the sac must herniate through the **thyrohyoid membrane**. Specifically, it passes through the same opening used by the **superior laryngeal artery and the internal branch of the superior laryngeal nerve**. This results in a reducible neck swelling that expands with increased intralaryngeal pressure (e.g., Valsalva maneuver). **2. Why the other options are incorrect:** * **Option A (Cricothyroid membrane):** This membrane connects the cricoid and thyroid cartilages. It is the site for emergency cricothyroidotomy but is not involved in the herniation of the laryngeal saccule. * **Option C (Laryngeal fold):** While an internal laryngocele may cause bulging of the false vocal folds (ventricular folds), the "herniation" into the neck—which defines the clinical presentation of a palpable mass—occurs through a membrane, not a fold. **3. High-Yield Clinical Pearls for NEET-PG:** * **The "Trumpeter’s Disease":** Laryngoceles are common in individuals who frequently increase intralaryngeal pressure (e.g., glassblowers, trumpet players). * **Rule out Malignancy:** In an elderly patient presenting with a laryngocele, it is mandatory to perform a direct laryngoscopy to rule out **Squamous Cell Carcinoma** obstructing the neck of the saccule. * **Diagnosis:** CT scan is the gold standard (shows an air-filled sac). * **Laryngopyocele:** If the air-filled sac becomes infected and filled with pus, it is termed a laryngopyocele.

Practice by Chapter

Acute Laryngitis

Practice Questions

Chronic Laryngitis

Practice Questions

Vocal Cord Nodules and Polyps

Practice Questions

Reinke's Edema

Practice Questions

Laryngeal Papillomatosis

Practice Questions

Vocal Cord Paralysis

Practice Questions

Laryngeal Trauma

Practice Questions

Laryngeal Stenosis

Practice Questions

Laryngeal Cancer

Practice Questions

Laryngomalacia

Practice Questions

Epiglottitis

Practice Questions

Voice Disorders

Practice Questions

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