Diseases of the Larynx Practice Questions

Q: A one-day-old neonate presents with a weak cry since birth and biphasic stridor, suggestive of incomplete canalisation. What is the most common site of this defect?

Glottic. ### Explanation The clinical presentation of a neonate with a **weak cry** and **biphasic stridor** since birth, specifically mentioning **incomplete canalisation**, points towards a **Laryngeal Web**. **1. Why Glottic is Correct:** Laryngeal webs result from the failure of the larynx to recanalize during the 10th week of intrauterine life. The **glottis (vocal cords)** is the most common site for this defect, accounting for approximately **75% of cases**. Because the web involves the vocal cords, it interferes with phonation (leading to a weak or muffled cry) and narrows the airway (causing stridor). **2. Analysis of Incorrect Options:** * **Supraglottic:** While congenital anomalies like laryngomalacia occur here, webs are rare in this region. Supraglottic lesions typically present with inspiratory stridor and a normal cry. * **Subglottic:** This is the second most common site for congenital narrowing (e.g., Subglottic Stenosis), but it is not the primary site for defects of "incomplete canalisation" (webs). Subglottic lesions usually present with a normal cry but significant biphasic stridor. * **Hypopharynx:** This area is part of the pharynx, not the larynx. Obstructions here usually present with feeding difficulties or muffled voice (hot potato voice) rather than true laryngeal stridor. **3. Clinical Pearls for NEET-PG:** * **Most common congenital anomaly of larynx:** Laryngomalacia (presents with inspiratory stridor). * **Most common site of Laryngeal Web:** Glottis (specifically the anterior commissure). * **Triad of Laryngeal Web:** Weak cry/hoarseness, croup-like cough, and varying degrees of respiratory obstruction (stridor). * **Association:** Large glottic webs may be associated with **Shprintzen syndrome (22q11.2 deletion)**. * **Management:** Small webs may require no treatment; thick webs require endoscopic laser excision or placement of a Silastic keel.

Q: Injury to the superior laryngeal nerve causes which of the following?

Loss of timbre of voice. The **Superior Laryngeal Nerve (SLN)** divides into two branches: the internal laryngeal nerve (sensory) and the **external laryngeal nerve (motor)**. The external branch supplies the **cricothyroid muscle**, which is the only intrinsic muscle of the larynx located outside the laryngeal framework. ### Why "Loss of timbre of voice" is correct: The cricothyroid muscle acts as a **tensor of the vocal cords**. It tilts the thyroid cartilage forward, lengthening and tightening the cords to increase the pitch of the voice. Injury to the SLN leads to paralysis of the cricothyroid, resulting in a loss of tension. This manifests clinically as: * **Loss of timbre (quality)** and range of voice. * Inability to produce high-pitched sounds (common in singers). * Easy vocal fatigue. ### Why other options are incorrect: * **A & B: Hoarseness and Paralysis of vocal cords:** These are characteristic of **Recurrent Laryngeal Nerve (RLN)** injury. The RLN supplies all other intrinsic muscles of the larynx and is responsible for vocal cord abduction/adduction. SLN injury alone does not cause significant hoarseness or cord paralysis. * **C: No effect:** While the voice may sound normal during routine conversation, there is a distinct functional deficit in pitch control and vocal strength. ### High-Yield Clinical Pearls for NEET-PG: * **Internal Laryngeal Nerve Injury:** Leads to anesthesia of the laryngeal mucosa above the vocal cords, increasing the risk of **aspiration**. * **Combined SLN and RLN Injury:** Results in the vocal cord being in the **cadaveric position** (midway between abducted and adducted). * **Wagner and Grossman Theory:** Suggests that if the SLN is intact in an RLN palsy, the vocal cord remains in the paramedian position due to the adducting action of the cricothyroid.

Q: A 38-year-old man presents with stridor following a respiratory infection. Cotton's grading is used to classify the pathology. Which of the following is the diagnosis?

Subglottic stenosis. **Explanation:** **Subglottic stenosis** is the correct diagnosis because **Cotton’s Grading System** is the gold-standard classification specifically used to quantify the severity of subglottic stenosis. It is based on the percentage of luminal narrowing: * **Grade I:** <50% obstruction * **Grade II:** 51–70% obstruction * **Grade III:** 71–99% obstruction * **Grade IV:** Complete obstruction (no detectable lumen) In this clinical scenario, the patient presents with **stridor** (a hallmark of airway narrowing) following a respiratory infection, which can trigger inflammatory stenosis or exacerbate a pre-existing subclinical narrowing. **Analysis of Incorrect Options:** * **Laryngeal Carcinoma:** While it causes stridor, it is staged using the **TNM classification**, not Cotton’s grading. * **Superior Laryngeal Nerve Palsy:** This typically presents with voice fatigue or loss of high-pitched notes (due to cricothyroid muscle paralysis) rather than fixed airway stenosis. * **Vocal Cord Misuse:** This leads to functional voice disorders or organic lesions like vocal nodules, which are not graded by Cotton’s system. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Iatrogenic (prolonged endotracheal intubation) is the most common cause of acquired subglottic stenosis. * **Anatomical Site:** The subglottis is the narrowest part of the pediatric airway (at the level of the cricoid cartilage). * **Management:** Grade I and II are often managed conservatively or endoscopically (dilation/laser), while Grade III and IV usually require surgical reconstruction (Laryngotracheal reconstruction or Cricotracheal resection).

Q: Which of the following childhood disorders is associated with an omega-shaped epiglottis?

Laryngomalacia. **Explanation:** **Laryngomalacia** is the most common congenital anomaly of the larynx and the leading cause of congenital stridor in infants. It is characterized by an abnormal softening of the supraglottic structures, which collapse inward during inspiration. The classic endoscopic finding is an **"omega-shaped" (Ω) epiglottis**, caused by the lateral folds of the epiglottis curling inward. This is often accompanied by short aryepiglottic folds and redundant arytenoid mucosa. **Analysis of Incorrect Options:** * **Epiglottitis:** This is an acute bacterial infection (typically *H. influenzae* type B) characterized by a "cherry-red," swollen epiglottis. On a lateral neck X-ray, it presents with the **"Thumb sign,"** not an omega shape. * **Subglottic Stenosis:** This involves narrowing of the airway below the vocal cords. It is characterized by the **"Steeple sign"** (subglottic narrowing) on an AP X-ray and is often associated with prolonged intubation. * **Choanal Atresia:** This is a congenital blockage of the posterior nasal passage. It presents with cyclical cyanosis (relieved by crying) and is diagnosed by the inability to pass a catheter through the nose. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Inspiratory stridor that worsens when the infant is supine, crying, or feeding, and improves when prone. * **Diagnosis:** Flexible fiberoptic laryngoscopy is the gold standard (shows collapse of supraglottic tissues). * **Management:** Most cases are self-limiting and resolve by 18–24 months. Severe cases (causing failure to thrive or cor pulmonale) require **supraglottoplasty**.

Q: A Blom-Singer prosthesis is used for voice rehabilitation following which surgical procedure?

Total laryngectomy. **Explanation:** The **Blom-Singer prosthesis** is a one-way silicone valve used for **Tracheoesophageal Puncture (TEP)** speech, which is currently the "gold standard" for voice rehabilitation following a **Total Laryngectomy**. **Why Total Laryngectomy is correct:** In a total laryngectomy, the entire larynx is removed, and the trachea is diverted to a permanent stoma in the neck, completely separating the airway from the food pipe (esophagus). This results in a loss of natural phonation. The Blom-Singer prosthesis is inserted into a surgically created fistula between the posterior wall of the trachea and the anterior wall of the esophagus. When the patient occludes the stoma and exhales, air is diverted through the valve into the esophagus, causing the pharyngoesophageal segment to vibrate and produce **esophageal speech**. **Why other options are incorrect:** * **Near-total laryngectomy:** This procedure preserves a small strip of endolaryngeal mucosa (a "shunt") that allows for spontaneous voice production without the need for a prosthetic valve. * **Hemi-laryngectomy:** This is a partial laryngectomy where only one vocal cord is removed. The patient retains a functional airway and the ability to speak using the remaining laryngeal structures, so a prosthesis is not required. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** It is a **one-way valve**; it allows air to move from the trachea to the esophagus but prevents food/liquid from entering the trachea (aspiration). * **Primary vs. Secondary TEP:** The prosthesis can be placed during the initial surgery (Primary) or weeks later (Secondary). * **Common Complication:** The most common reason for prosthesis failure/leakage is **fungal (Candida) colonization** or widening of the TEP tract. * **Other Voice Options:** Other methods post-laryngectomy include the **Electrolarynx** (external device) and traditional **Esophageal Speech** (burping air).

Q: A 2-week-old neonate presents with stridor in the prone position. What is the recommended management?

Observation and watchful waiting. **Explanation:** The clinical presentation describes **Laryngomalacia**, the most common cause of congenital stridor in neonates. It is characterized by an inspiratory stridor that typically worsens when the infant is supine, crying, or feeding, and notably **improves in the prone position** (due to the forward displacement of the tongue and supraglottic structures). **Why Option C is Correct:** In over 90% of cases, laryngomalacia is a self-limiting condition. As the laryngeal cartilage matures and strengthens, the stridor typically resolves spontaneously by 18–24 months of age. Therefore, **observation and watchful waiting** is the standard management for mild to moderate cases where the infant is feeding well and gaining weight. **Why Other Options are Incorrect:** * **Option A:** Calcium supplementation is used for laryngospasm due to hypocalcemic tetany, not for structural anomalies like laryngomalacia. * **Option B:** Nebulization (e.g., adrenaline or saline) is indicated for inflammatory conditions like Croup (Laryngotracheobronchitis), but it does not correct the anatomical collapse seen in laryngomalacia. * **Option C:** Antibiotics are used for infectious causes of airway obstruction (e.g., Epiglottitis or Bacterial Tracheitis), which present with fever and acute distress, unlike this neonate. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Usually clinical; definitive diagnosis is via **flexible fiberoptic laryngoscopy** (shows "omega-shaped" epiglottis and inward collapse of aryepiglottic folds). * **Surgical Indication:** **Supraglottoplasty** is only indicated in "Severe Laryngomalacia" (characterized by failure to thrive, cor pulmonale, or severe apnea). * **Association:** Frequently associated with **Gastroesophageal Reflux Disease (GERD)**, which can exacerbate the stridor.

Q: Regarding juvenile papillomas, which of the following statements is/are true?

Multiple, Seen in children, Recurrent, Associated with HPV. **Explanation:** Juvenile-onset Recurrent Respiratory Papillomatosis (JORRP) is the most common benign neoplasm of the larynx in children. The correct answer is **C** because it accurately captures the four hallmark characteristics of the disease: 1. **Multiple:** Unlike the adult form (which is often a single pedunculated lesion), juvenile papillomas are typically **multicentric** and sessile, involving the true vocal cords, false cords, and epiglottis. 2. **Seen in children:** It usually presents between ages 2 and 5. Transmission is thought to occur during childbirth through an infected birth canal. 3. **Recurrent:** These tumors are notorious for their aggressive recurrence after surgical excision, often requiring multiple procedures. 4. **Associated with HPV:** It is caused by **Human Papillomavirus (HPV) types 6 and 11**. **Analysis of Incorrect Options:** * **Options B & D:** These are incorrect because juvenile papillomas are rarely "single." A single papilloma is characteristic of the **Adult-onset** variety, which is usually solitary and has a lower rate of recurrence. * **Option A:** While these descriptors are correct, they are incomplete. In NEET-PG, the most comprehensive option that includes the viral etiology (HPV) is the preferred answer. **Clinical Pearls for NEET-PG:** * **Most common site:** True vocal cords. * **Presenting symptom:** Hoarseness of voice (most common) or stridor. * **Treatment of choice:** CO2 Laser excision or Microdebridement. * **Adjuvant therapy:** Cidofovir (antiviral) is used in severe, rapidly recurring cases. * **Malignant transformation:** Rare, but can occur (usually to Squamous Cell Carcinoma), especially if associated with HPV-16 or 18.

Question 1

A one-day-old neonate presents with a weak cry since birth and biphasic stridor, suggestive of incomplete canalisation. What is the most common site of this defect?

Accepted Answer

Glottic

Answer

Supraglottic

Answer

Subglottic

Answer

Hypopharynx

Question 2

In acute epiglottitis, what is the common cause of death?

Accepted Answer

Respiratory obstruction

Answer

Acidosis

Answer

Atelectasis

Answer

Laryngospasm

Question 3

Maximum stridor is seen in which condition of vocal cord paralysis?

Accepted Answer

Bilateral incomplete paralysis

Answer

Unilateral incomplete paralysis

Answer

Unilateral complete paralysis

Answer

Bilateral complete paralysis

Question 4

Injury to the superior laryngeal nerve causes which of the following?

Accepted Answer

Loss of timbre of voice

Answer

Hoarseness

Answer

Paralysis of vocal cords

Answer

No effect

Question 5

A 38-year-old man presents with stridor following a respiratory infection. Cotton's grading is used to classify the pathology. Which of the following is the diagnosis?

Accepted Answer

Subglottic stenosis

Answer

Laryngeal carcinoma

Answer

Superior laryngeal nerve palsy

Answer

Vocal cord misuse

Question 6

Which of the following childhood disorders is associated with an omega-shaped epiglottis?

Accepted Answer

Laryngomalacia

Answer

Epiglottitis

Answer

Subglottic stenosis

Answer

Choanal atresia

Question 7

A Blom-Singer prosthesis is used for voice rehabilitation following which surgical procedure?

Accepted Answer

Total laryngectomy

Answer

Near total laryngectomy

Answer

Hemi laryngectomy

Answer

None of the above

Question 8

A 2-week-old neonate presents with stridor in the prone position. What is the recommended management?

Accepted Answer

Observation and watchful waiting

Answer

Oral calcium supplementation

Answer

Nebulization therapy

Answer

Antibiotic administration

Question 9

Which substance is associated with minimal tissue reaction in injection laryngoplasty?

Accepted Answer

Calcium hydroxyapatite

Answer

Fat

Answer

Gelfoam

Answer

Bioplastique

Question 10

Regarding juvenile papillomas, which of the following statements is/are true?

Accepted Answer

Multiple, Seen in children, Recurrent, Associated with HPV

Answer

Multiple, Seen in children, Recurrent

Answer

Single, Multiple, Seen in children

Answer

Single, Seen in children, Recurrent, Associated with HPV

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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