Diseases of the Larynx Practice Questions

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.

Q: What is the subglottic diameter less than which is considered subglottic stenosis in term infants?

4 mm. ### Explanation **Subglottic stenosis (SGS)** is defined as a narrowing of the subglottic airway, which is the narrowest part of the pediatric airway (at the level of the cricoid cartilage). **1. Why 4 mm is the Correct Answer:** In a healthy, full-term neonate, the normal subglottic diameter is approximately **4.5 to 5 mm**. According to the standard clinical definition, subglottic stenosis is diagnosed when the diameter of the subglottis is **less than 4 mm** in a full-term infant. In premature infants, the threshold is lower, typically considered less than **3 mm**. **2. Analysis of Incorrect Options:** * **Option A (2 mm):** This represents a critical, life-threatening narrowing. While it is technically stenosis, it is far below the diagnostic threshold. * **Option B (3 mm):** This is the diagnostic cutoff for **premature infants**, but not for term infants. * **Option D (5 mm):** This is considered the lower limit of the **normal range** for a term infant. **3. Clinical Pearls for NEET-PG:** * **Most Common Cause:** Congenital SGS is the third most common congenital anomaly of the larynx (after laryngomalacia and vocal cord paralysis). However, **acquired SGS** (due to prolonged endotracheal intubation) is more common overall. * **Grading System:** The **Cotton-Myer Classification** is used to grade the severity based on the percentage of lumen reduction: * Grade I: <50% obstruction * Grade II: 51–70% * Grade III: 71–99% * Grade IV: No detectable lumen (complete atresia) * **Clinical Presentation:** The hallmark sign is **biphasic stridor**. * **Management:** Mild cases (Grade I/II) may be managed conservatively; severe cases (Grade III/IV) often require surgical intervention like **Laryngotracheal Reconstruction (LTR)** or **Cricotracheal Resection (CTR)**.

Q: All of the following are true about adult laryngeal papilloma except:

Typically found in the posterior half of the vocal cord. **Explanation:** Laryngeal papillomas are benign epithelial tumors caused by Human Papillomavirus (HPV types 6 and 11). They are classified into Juvenile-onset and Adult-onset types, which have distinct clinical profiles. **Why Option C is the Correct Answer (The False Statement):** Laryngeal papillomas, especially the adult variety, typically involve the **anterior half** of the vocal cords or the anterior commissure. They tend to occur at "junctional zones" where ciliated columnar epithelium meets squamous epithelium. Finding a lesion primarily in the posterior larynx is atypical and should raise suspicion for other pathologies like contact granulomas or tuberculosis. **Analysis of Other Options:** * **Option A (More common in males):** Unlike the juvenile form (which has an equal sex distribution), adult-onset laryngeal papilloma shows a significant **male preponderance**. * **Option B (Do not recur):** While adult papillomas are often solitary, they **frequently recur** after surgery. Although the recurrence rate is lower than in the juvenile-onset respiratory papillomatosis (JORP), multiple sittings are often required. * **Option D (Treatment is primarily surgical):** The gold standard treatment is **Microlaryngeal Surgery (MLS)** using CO2 laser or microdebrider to debulk the lesion while preserving the underlying vocal cord structure. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** HPV 6 and 11 (Low risk for malignancy, though adult types have a slightly higher risk of malignant transformation than juvenile types). * **Presentation:** Hoarseness of voice is the most common presenting symptom. * **Adjuvant Therapy:** Cidofovir (intralesional injection) is the most common adjuvant used for aggressive recurrences. * **Key Difference:** Juvenile type is often multiple and aggressive; Adult type is usually solitary and less aggressive.

Q: Which of the following can cause bilateral recurrent laryngeal nerve palsy?

Thyroid surgery, thyroid malignancy, and viral infection. **Explanation:** Recurrent Laryngeal Nerve (RLN) palsy can be unilateral or bilateral. For a condition to cause **bilateral** palsy, it must either involve a midline structure, affect both sides of the neck/mediastinum simultaneously, or be a systemic process. 1. **Why Option B is correct:** * **Thyroid Surgery:** This is the most common cause of bilateral RLN injury. During total thyroidectomy, both nerves are at risk due to their proximity to the gland. * **Thyroid Malignancy:** Advanced thyroid carcinoma (especially anaplastic or invasive papillary) can infiltrate both nerves as they ascend in the tracheoesophageal groove. * **Viral Infection:** Post-viral neuritis (e.g., following Influenza or Herpes) can cause idiopathic bilateral vocal cord paralysis, often presenting as sudden onset airway compromise. 2. **Why other options are incorrect:** * **Aneurysm of the Arch of Aorta (Options A & C):** This is a classic cause of **unilateral** (left-sided) RLN palsy (Ortner’s syndrome). The left RLN loops under the aortic arch, while the right RLN loops under the subclavian artery. An aortic aneurysm cannot anatomically cause bilateral palsy unless there is a separate pathology on the right side. * **Option D:** While correct, it is incomplete. Viral infections are a recognized clinical etiology for bilateral involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Position of cords:** In bilateral RLN palsy, cords usually lie in the **median or paramedian position** because the cricothyroid muscle (supplied by the Superior Laryngeal Nerve) is still functional and adducts the cords. * **Clinical Presentation:** The primary symptom of bilateral RLN palsy is **stridor and dyspnea**, whereas the primary symptom of unilateral palsy is **hoarseness**. * **Management:** Acute bilateral palsy is a medical emergency often requiring **tracheostomy** to secure the airway.

Q: Which drug is locally used for tracheal stenosis?

Mitomycin C. **Explanation:** **Mitomycin C (Option A)** is the correct answer. It is a potent fibroblast inhibitor and an alkylating agent derived from *Streptomyces caespitosus*. In the management of tracheal or subglottic stenosis, it is used topically (usually at a concentration of 0.4 mg/ml) following endoscopic dilation or laser resection. Its primary mechanism is the inhibition of DNA synthesis, which prevents the proliferation of fibroblasts and the synthesis of collagen. This reduces the formation of excessive scar tissue (granulation), thereby maintaining the patency of the airway and decreasing the rate of restenosis. **Why the other options are incorrect:** * **Doxorubicin (Option B):** An anthracycline chemotherapy agent used systemically for various malignancies (e.g., breast cancer, lymphomas). It has no established role in the local management of airway stenosis. * **Bleomycin (Option C):** While used intralesionally for hemangiomas or warts, it is not the standard of care for tracheal stenosis. Its primary side effect is pulmonary fibrosis, making it unsuitable for this specific application. * **Clindamycin (Option D):** A lincosamide antibiotic used to treat anaerobic infections. It does not possess the anti-fibrotic properties required to prevent cicatricial stenosis. **High-Yield Clinical Pearls for NEET-PG:** * **Application:** Mitomycin C is applied topically via a soaked cottonoid for 2–5 minutes. * **Other ENT uses:** It is also used topically in **Dacryocystorhinostomy (DCR)** and **Myringotomy** to prevent the closure of the surgical stoma/opening. * **Adjuvant Therapy:** In tracheal stenosis, it is often used alongside **systemic or intralesional steroids** (like Triamcinolone) to further suppress inflammation.

Question 1

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 2

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 3

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

Question 4

Which of the following is NOT a contraindication for bronchoscopy?

Accepted Answer

Active bleeding

Answer

Lesions of the cervical spine

Answer

Cardiac failure

Answer

Trismus

Question 5

When caring for a male patient who has just had a total laryngectomy, what should the nurse plan to do?

Accepted Answer

Develop an alternative communication method

Answer

Encourage oral feeding as soon as possible

Answer

Keep the tracheostomy cuff fully inflated

Answer

Keep the patient flat in bed

Question 6

What is the subglottic diameter less than which is considered subglottic stenosis in term infants?

Accepted Answer

4 mm

Answer

2 mm

Answer

3 mm

Answer

5 mm

Question 7

All of the following are true about adult laryngeal papilloma except:

Accepted Answer

Typically found in the posterior half of the vocal cord

Answer

More common in males than females

Answer

Do not recur

Answer

Treatment is primarily surgical

Question 8

A 10-year-old boy developed hoarseness of voice following an attack of diphtheria. On examination, his right vocal cord was paralyzed. What is the treatment of choice for a paralyzed vocal cord in this scenario?

Accepted Answer

Wait for spontaneous recovery of the vocal cord

Answer

Gel foam injection of the right vocal cord

Answer

Fat injection of the right vocal cord

Answer

Thyroplasty type-I

Question 9

Which of the following can cause bilateral recurrent laryngeal nerve palsy?

Accepted Answer

Thyroid surgery, thyroid malignancy, and viral infection

Answer

Thyroid surgery, aneurysm of the arch of aorta, and viral infection

Answer

Thyroid surgery, thyroid malignancy, and aneurysm of the arch of aorta

Answer

Thyroid surgery and thyroid malignancy

Question 10

Which drug is locally used for tracheal stenosis?

Accepted Answer

Mitomycin C

Answer

Doxorubicin

Answer

Bleomycin

Answer

Clindamycin

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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