Diseases of the Larynx — MCQs

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 51: Which of the following is NOT a contraindication for bronchoscopy?

A. Lesions of the cervical spine
B. Cardiac failure
C. Active bleeding (Correct Answer)
D. Trismus

Explanation: **Explanation:** The question asks to identify which condition is **not** a contraindication for bronchoscopy. In clinical practice, **active bleeding** (hemoptysis) is actually one of the primary **indications** for performing a bronchoscopy, as it is essential to localize the site of bleeding and potentially intervene (e.g., via iced saline lavage or balloon tamponade). **Why Active Bleeding is the Correct Answer:** While massive hemoptysis can make visualization difficult, it is not a contraindication. Bronchoscopy is the gold standard for identifying the source of endobronchial bleeding. In cases of active bleeding, a rigid bronchoscope is often preferred over a flexible one because it allows for better suctioning of clots and maintains a secure airway. **Analysis of Incorrect Options (Contraindications):** * **Lesions of the Cervical Spine (A):** Rigid bronchoscopy requires significant extension of the neck to align the oral, pharyngeal, and laryngeal axes. In patients with cervical fractures or severe spondylosis, this maneuver can lead to permanent neurological damage or paralysis. * **Cardiac Failure (B):** Severe cardiac instability, recent myocardial infarction, or uncontrolled heart failure are absolute contraindications. The procedure causes significant sympathetic stimulation (tachycardia/hypertension) and potential hypoxia, which can precipitate a fatal arrhythmia or cardiac arrest. * **Trismus (D):** The inability to open the mouth (due to infection, trauma, or TMJ issues) acts as a physical barrier to the insertion of the bronchoscope, especially the rigid type. **High-Yield Clinical Pearls for NEET-PG:** * **Rigid vs. Flexible:** Rigid bronchoscopy is the treatment of choice for **foreign body removal** and **massive hemoptysis**. Flexible bronchoscopy is preferred for diagnostic purposes and peripheral lung lesions. * **Absolute Contraindication:** The most significant absolute contraindication for flexible bronchoscopy is the inability to oxygenate the patient during the procedure. * **Anesthesia:** Rigid bronchoscopy is always performed under **General Anesthesia**, whereas flexible bronchoscopy can be done under local anesthesia with sedation.

Question 52: When caring for a male patient who has just had a total laryngectomy, what should the nurse plan to do?

A. Encourage oral feeding as soon as possible
B. Develop an alternative communication method (Correct Answer)
C. Keep the tracheostomy cuff fully inflated
D. Keep the patient flat in bed

Explanation: **Explanation:** In a **Total Laryngectomy**, the entire larynx (including the vocal cords) is surgically removed, and the trachea is diverted to a permanent stoma in the neck. This results in a complete loss of natural voice, which is often the most distressing immediate postoperative challenge for the patient. **Why Option B is Correct:** Since the patient can no longer speak, establishing an **alternative communication method** (e.g., writing pads, communication boards, or gestures) is the highest priority in the immediate postoperative plan. This ensures the patient can express needs, report pain, and reduce psychological distress. **Analysis of Incorrect Options:** * **Option A:** Oral feeding is strictly contraindicated in the early postoperative period (usually for 7–10 days) to allow the pharyngeal suture line to heal and prevent **pharyngocutaneous fistulas**. Patients are typically fed via a Nasogastric (NG) tube. * **Option C:** While a laryngectomy creates a stoma, a cuffed tube is generally not kept "fully inflated" long-term as it can cause tracheal wall necrosis. Furthermore, the airway is anatomically separated from the esophagus, so the risk of aspiration from the oral cavity is eliminated. * **Option D:** Patients should be kept in a **Semi-Fowler’s position** (30–45 degrees) to reduce neck edema, facilitate lung expansion, and decrease tension on the suture line. **NEET-PG High-Yield Pearls:** * **Anatomy:** After total laryngectomy, there is no longer a connection between the pharynx and the trachea (the patient becomes a "total neck breather"). * **Voice Rehabilitation:** Options include **Tracheoesophageal Puncture (TEP)** with a prosthesis (Gold Standard), Electrolarynx, or Esophageal speech. * **Complication:** The most common post-op complication is a **Pharyngocutaneous fistula**. * **Olfaction:** Patients often experience **anosmia** because they can no longer sniff air through the nose.

Question 53: True about laryngitis sicca?

A. Caused by Klebsiella ozaenae
B. Caused by Klebsiella rhinoscleromatis (Correct Answer)
C. Hemorrhagic crust formation seen
D. Antifungal are effective

Explanation: **Explanation:** **Laryngitis Sicca** (also known as Atrophic Laryngitis) is a chronic inflammatory condition characterized by the atrophy of the laryngeal mucosa and mucous-secreting glands. 1. **Why Option B is Correct:** While Laryngitis Sicca is often associated with environmental factors (dust, dry air) or post-radiotherapy, its specific infectious etiology is linked to **Klebsiella rhinoscleromatis** (the Frisch bacillus). This organism is the causative agent of Rhinoscleroma, which can involve the larynx (Scleroma of the larynx), leading to crusting and mucosal atrophy. 2. **Why other options are incorrect:** * **Option A:** *Klebsiella ozaenae* is primarily associated with Atrophic Rhinitis (Ozena) of the nasal cavity, not specifically the laryngeal manifestation of sicca. * **Option C:** The hallmark of Laryngitis Sicca is the formation of **foul-smelling, greenish-black crusts** that are dry and tenacious. Hemorrhagic (bloody) crusts are more characteristic of acute viral infections or specific granulomatous diseases like Wegener’s. * **Option D:** Since the condition is bacterial or environmental in origin, **antifungals have no role**. Treatment focuses on humidification, alkaline glottic washes, and sometimes Ammonium chloride to liquefy secretions. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Atrophy:** Often co-exists with atrophic rhinitis and atrophic pharyngitis. * **Clinical Presentation:** The most common symptom is **hoarseness of voice** and a dry, irritating cough, which improves once the crusts are coughed out. * **Key Pathology:** Squamous metaplasia of the laryngeal epithelium and atrophy of the seromucinous glands. * **Management:** Steam inhalation and "Mandl's paint" (iodine-based) are frequently used to stimulate glandular secretion.

Question 54: Laryngocele arises as a herniation of laryngeal mucosa through which membrane?

A. Thyrohyoid (Correct Answer)
B. Cricothyroid
C. Crico-tracheal
D. Cricosternal

Explanation: ### Explanation **1. Why Thyrohyoid is Correct:** A laryngocele is an abnormal cystic dilatation of the **saccule of the laryngeal ventricle**. The saccule (or pouch of Hilton) is a blind-ending pouch located between the vestibular fold and the inner surface of the thyroid cartilage. When the saccule distends with air and extends superiorly, it eventually exits the larynx by piercing the **thyrohyoid membrane**. Specifically, it passes through the same opening used by the **internal laryngeal nerve and superior laryngeal artery**. * **Internal Laryngocele:** Remains within the thyroid cartilage (displaces false vocal folds). * **External Laryngocele:** Herniates through the thyrohyoid membrane and presents as a neck mass. **2. Why Other Options are Incorrect:** * **Cricothyroid Membrane:** This membrane connects the cricoid and thyroid cartilages. It is the site for emergency cricothyrotomy, not the exit point for the saccule. * **Crico-tracheal Membrane:** This connects the cricoid cartilage to the first tracheal ring. It is involved in subglottic pathology or trauma, not laryngocele formation. * **Cricosternal:** This is not a standard anatomical membrane of the larynx; the larynx is separated from the sternum by the trachea and strap muscles. **3. NEET-PG High-Yield Pearls:** * **Etiology:** Often seen in individuals with increased intra-laryngeal pressure (e.g., **trumpet players, glass blowers**, or chronic coughers). * **Clinical Presentation:** External laryngoceles typically present as a **reducible, resonant neck swelling** that increases in size with the Valsalva maneuver (Bryce’s Sign). * **Association:** In adults, a laryngocele may be secondary to a **squamous cell carcinoma** obstructing the ventricular orifice; thus, endoscopic evaluation is mandatory. * **Investigation of Choice:** CT scan (shows an air-filled sac).

Question 55: All of the following are true about adult laryngeal papilloma except:

A. More common in males than females
B. Do not recur
C. Typically found in the posterior half of the vocal cord (Correct Answer)
D. Treatment is primarily surgical

Explanation: **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.

Question 56: 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?

A. Gel foam injection of the right vocal cord
B. Fat injection of the right vocal cord
C. Thyroplasty type-I
D. Wait for spontaneous recovery of the vocal cord (Correct Answer)

Explanation: ### Explanation **1. Why "Wait for spontaneous recovery" is correct:** The clinical scenario describes a case of **post-diphtheritic paralysis**. Diphtheria produces an exotoxin that causes demyelination of nerves, leading to neuropathies. In the larynx, this typically manifests as a lower motor neuron lesion of the vagus or recurrent laryngeal nerve. The key medical concept here is that post-diphtheritic nerve paralysis is **transient and reversible**. The demyelination is not permanent, and nerve function typically returns to normal once the toxin is cleared and the nerve remyelinates. Therefore, the standard of care is conservative management and observation for at least **6 to 12 months** before considering any surgical intervention. **2. Why the other options are incorrect:** * **Options A & B (Gelfoam/Fat Injection):** These are forms of **Injection Laryngoplasty** used to medialize a paralyzed cord to improve voice and prevent aspiration. However, they are indicated only if there is no hope of recovery or if the patient is at high risk of aspiration. In a child with a reversible condition, invasive procedures are avoided. * **Option C (Thyroplasty Type-I):** This is a permanent surgical medialization procedure (Isshiki Type I). It involves placing a silastic or Gore-Tex wedge to push the cord to the midline. It is contraindicated in cases where spontaneous recovery is expected, as it would lead to an over-corrected airway once the nerve recovers. **3. Clinical Pearls for NEET-PG:** * **Diphtheria & Nerves:** The most common neurological complication of diphtheria is **palatal paralysis** (occurring in the 3rd week), followed by ocular and then laryngeal/respiratory paralysis (5th–7th week). * **Wait Time:** For any idiopathic or post-viral vocal cord paralysis, always wait **6–12 months** for spontaneous recovery before performing permanent medialization. * **Thyroplasty Types:** * Type I: Medialization (for paralysis). * Type II: Lateralization (for spasmodic dysphonia). * Type III: Relaxation/Shortening (to lower pitch). * Type IV: Stretching/Tension (to raise pitch).

Question 57: Tracheostomy reduces dead space by which of the following mechanisms?

A. By-passing the upper airway (Correct Answer)
B. Increased V/Q ratio
C. Reducing airflow resistance
D. By all of the above mechanisms

Explanation: ### Explanation **1. Why Option A is Correct:** The primary mechanism by which tracheostomy reduces anatomical dead space is by **bypassing the upper respiratory tract** (nose, mouth, pharynx, and larynx). In a normal adult, the anatomical dead space is approximately 150 ml. By creating an opening directly into the trachea, the volume of air that does not participate in gas exchange is significantly decreased—by roughly **30% to 50% (approx. 70–100 ml)**. This reduction is particularly beneficial in patients with limited respiratory reserve, as it improves alveolar ventilation. **2. Why Other Options are Incorrect:** * **Option B (Increased V/Q ratio):** Tracheostomy does not inherently increase the Ventilation-Perfusion (V/Q) ratio. While it improves ventilation efficiency, the V/Q ratio is a complex relationship involving pulmonary blood flow and alveolar air, which is not the primary mechanism of dead space reduction. * **Option C (Reducing airflow resistance):** While tracheostomy *does* reduce airflow resistance (by providing a shorter, wider, and more direct path than the upper airway), this is a separate physiological benefit. Reducing resistance decreases the **work of breathing**, but it is not the mechanism that defines "dead space reduction." * **Option D:** Since only the bypass of the upper airway directly accounts for the reduction in anatomical volume (dead space), "All of the above" is incorrect. **3. Clinical Pearls for NEET-PG:** * **Dead Space Reduction:** Tracheostomy reduces dead space by ~50%. * **Work of Breathing:** It reduces resistance to airflow, making it easier for patients with chronic respiratory failure to breathe. * **Indications:** The most common indication for tracheostomy in the ICU is **prolonged intubation** (to prevent subglottic stenosis). * **Emergency Site:** In an acute "cannot intubate, cannot ventilate" scenario, **Cricothyroidotomy** is the procedure of choice, not a formal tracheostomy. * **Level of Tracheostomy:** Usually performed between the **2nd and 3rd (or 3rd and 4th) tracheal rings**.

Question 58: 'Thumbprint' sign is seen in which of the following conditions?

A. Candida infection
B. Aspergillus infection
C. Thermomyces infection
D. Epiglottitis (Correct Answer)

Explanation: **Explanation:** The **'Thumbprint' sign** is a classic radiological finding seen on a **lateral neck X-ray** in patients with **Acute Epiglottitis**. It represents a swollen, edematous epiglottis that loses its normal thin, leaf-like appearance and instead resembles the distal silhouette of a human thumb. **Why Epiglottitis is correct:** Acute Epiglottitis is a life-threatening inflammatory condition, most commonly caused by *Haemophilus influenzae* type B (HiB). The inflammation leads to massive supraglottic edema. On a lateral soft tissue X-ray of the neck, this swelling narrows the vallecula and creates the characteristic rounded "thumb-like" opacity. **Why the other options are incorrect:** * **Options A, B, and C (Fungal Infections):** Candida, Aspergillus, and Thermomyces are fungal pathogens. While they can cause laryngeal infections (especially in immunocompromised patients), they typically present with white plaques, ulcerative lesions, or necrotizing tissue rather than the acute, massive supraglottic edema required to produce the thumbprint sign. These are not associated with this specific radiological hallmark. **Clinical Pearls for NEET-PG:** * **Clinical Triad:** Drooling, Dysphagia, and Distress (the 3 D’s). * **Positioning:** Patients often assume the **'Tripod position'** (leaning forward with hands on knees) to maintain the airway. * **Management:** The priority is **airway maintenance** (intubation or tracheostomy). **Never** examine the throat with a tongue depressor in a suspected case, as it can trigger fatal laryngospasm. * **Differential Diagnosis:** Contrast this with **Croup (Laryngotracheobronchitis)**, which shows the **'Steeple sign'** (subglottic narrowing) on an Anteroposterior (AP) view.

Question 59: In the erect posture, what is the most common site for a foreign body in the bronchus?

A. Right lower lobe (Correct Answer)
B. Right upper lobe
C. Carina
D. Left lower lobe

Explanation: **Explanation:** The preference for a foreign body (FB) to lodge in the **Right Lower Lobe** is dictated by the anatomical configuration of the tracheobronchial tree and the influence of gravity. **1. Why the Right Lower Lobe is Correct:** * **Anatomy of the Right Main Bronchus:** Compared to the left, the right main bronchus is **wider, shorter, and more vertical** (forming an angle of approximately 25° with the trachea, whereas the left forms a 45° angle). This makes it a more direct path for aspirated objects. * **Gravity and Posture:** In the **erect (standing/sitting) posture**, gravity directs the object straight down the vertical path of the right main bronchus. The **Right Lower Lobe bronchus** is the most direct continuation of the right main bronchus, making it the most frequent terminal destination. **2. Why other options are incorrect:** * **Right upper lobe:** This is rarely involved in the erect posture because the upper lobe bronchus arises at a sharp, superior angle, requiring the object to "defy" gravity. (Note: This is a common site for aspiration pneumonia in the *prone* position). * **Carina:** While large or irregular FBs may wedge at the carina, most objects small enough to pass the glottis will drop into one of the main bronchi. * **Left lower lobe:** The left main bronchus is narrower and more horizontal due to the displacement by the heart, making it less likely to receive a foreign body than the right side. **Clinical Pearls for NEET-PG:** * **Most common site overall:** Right Main Bronchus (specifically the lower lobe in erect posture). * **Most common site in Supine position:** Superior segment of the Right Lower Lobe or the Posterior segment of the Right Upper Lobe. * **Radiology:** Most FBs are **radiolucent** (vegetable matter like peanuts). Look for indirect signs like obstructive emphysema (check-valve effect) or atelectasis (stop-valve effect). * **Gold Standard Management:** Rigid Bronchoscopy.

Question 60: Which of the following can cause bilateral recurrent laryngeal nerve palsy?

A. Thyroid surgery, aneurysm of the arch of aorta, and viral infection
B. Thyroid surgery, thyroid malignancy, and viral infection (Correct Answer)
C. Thyroid surgery, thyroid malignancy, and aneurysm of the arch of aorta
D. Thyroid surgery and thyroid malignancy

Explanation: **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.

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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