Diseases of the Larynx Practice Questions

Q: Which of the following are indications for tracheostomy?

All of the above. 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.

Q: Stridor is caused by all except:

Asthma. **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.

Q: 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?

Reactive nodule. ### 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**.

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

Surgical causes. **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.

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

It is more common on the left side.. **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).

Q: 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?

Laryngopharyngeal reflux. **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.

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

Laryngectomy. **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.

Q: 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?

Thyrohyoid membrane. ### 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.

Question 1

Which of the following are indications for tracheostomy?

Accepted Answer

All of the above

Answer

Flail chest

Answer

Head injury

Answer

Tetanus

Question 2

Stridor is caused by all except:

Accepted Answer

Asthma

Answer

Hypocalcemia

Answer

Epiglottitis

Answer

Laryngeal tumor

Question 3

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?

Accepted Answer

Reactive nodule

Answer

Croup

Answer

Epiglottitis

Answer

Squamous cell carcinoma

Question 4

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

Accepted Answer

Surgical causes

Answer

Trauma

Answer

Malignancy

Answer

Inflammatory causes

Question 5

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

Accepted Answer

It is more common on the left side.

Answer

It is idiopathic in 50% of cases.

Answer

The vocal cord will lie in a lateral position.

Answer

Speech therapy is the primary treatment.

Question 6

What is an indication for tracheostomy?

Accepted Answer

Foreign body obstructing the airway

Answer

Vocal cord replacement

Answer

Pharynx replacement

Answer

Tracheomalacia

Question 7

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?

Accepted Answer

Laryngopharyngeal reflux

Answer

Vocal abuse

Answer

Tuberculosis

Answer

Chronic steroid use

Question 8

All of the following are true regarding tracheostomy tube except:

Accepted Answer

Ideally should be changed every 3rd day

Answer

Double lumen tube

Answer

Made of titanium silver alloy

Answer

Cuffed tube prevents aspiration of pharyngeal secretions

Question 9

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

Accepted Answer

Laryngectomy

Answer

Radiotherapy followed by surgery

Answer

Chemotherapy

Answer

None of the above

Question 10

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?

Accepted Answer

Thyrohyoid membrane

Answer

Cricothyroid membrane

Answer

Laryngeal fold

Answer

None of the above

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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