Diseases of the Larynx Practice Questions

Q: Direct bronchoscopy can visualize all except:

Subcarinal lymph nodes. **Explanation:** The core concept here is the difference between **endoscopy** (visualizing the lumen) and **imaging/transbronchial techniques**. Direct bronchoscopy involves passing a rigid or flexible scope through the larynx into the tracheobronchial tree to visualize the internal mucosal surfaces. * **Why Option D is correct:** Subcarinal lymph nodes are **extraluminal** structures located outside the airway, beneath the bifurcation of the trachea (carina). While a bronchoscopist might see an "extrinsic bulge" if these nodes are enlarged, the nodes themselves cannot be visualized directly through a standard bronchoscope. To see or sample them, advanced techniques like **Endobronchial Ultrasound (EBUS)** or Transbronchial Needle Aspiration (TBNA) are required. * **Why Options A, B, and C are incorrect:** * **Vocal cords (B):** These are the first structures encountered as the bronchoscope passes through the glottis. * **Trachea (A):** This is the main conduit through which the scope passes to reach the lungs. * **First segmental subdivision (C):** Modern bronchoscopes (especially flexible ones) can easily reach the lobar bronchi and the first few segmental subdivisions to inspect the mucosa and openings. **High-Yield Clinical Pearls for NEET-PG:** 1. **Carina:** The most sensitive area of the tracheobronchial tree; its widening usually indicates enlargement of subcarinal lymph nodes (often due to malignancy or sarcoidosis). 2. **Foreign Body:** The most common site for an inhaled foreign body is the **Right Main Bronchus** because it is shorter, wider, and more vertical than the left. 3. **Killian's Dehiscence:** A weak point in the pharynx, but remember that for bronchoscopy, the primary landmark for safety is the **vocal cords**.

Q: A laryngocele develops from which anatomical structure?

Ventricular saccule. ### Explanation **Correct Answer: B. Ventricular saccule** **Pathophysiology:** A **laryngocele** is an abnormal, air-filled dilation of the **saccule of the laryngeal ventricle** (also known as the *appendix of the ventricle*). The saccule is a blind pouch that arises from the anterior part of the ventricle and extends upward between the vestibular fold (false cord) and the thyroid cartilage. When the saccule becomes abnormally enlarged and maintains communication with the laryngeal lumen, it is termed a laryngocele. This condition is often associated with activities that increase intralaryngeal pressure, such as glassblowing or playing wind instruments. **Analysis of Incorrect Options:** * **A. Thyroid cartilage:** While the laryngocele lies medial to the thyroid cartilage, it does not originate from it. The cartilage provides the structural framework but is not the site of mucosal herniation. * **C. Cricoid cartilage:** This is the only complete cartilaginous ring of the airway. It is located below the level of the glottis and is not involved in the formation of the saccule or ventricle. * **D. Epiglottis:** The epiglottis is a fibroelastic cartilage that prevents aspiration. While a laryngocele may displace the epiglottis or vallecula, it does not arise from this structure. **High-Yield Clinical Pearls for NEET-PG:** * **Types:** 1. **Internal:** Limited to the larynx (causes hoarseness/stridor). 2. **External:** Herniates through the **thyrohyoid membrane** (presents as a neck mass that expands with the Valsalva maneuver). 3. **Mixed:** Features of both. * **Bryce’s Sign:** Gurgling sound heard on compression of the external laryngocele. * **Association:** In adults, a laryngocele can be secondary to a **squamous cell carcinoma** obstructing the ventricular orifice; therefore, endoscopic evaluation is mandatory. * **Laryngopyocele:** When a laryngocele becomes infected and filled with pus.

Q: What is laryngofissure?

Opening the larynx in the midline. **Explanation:** **Laryngofissure** (also known as a Median Thyrotomy) is a surgical procedure where the larynx is opened vertically through the midline. This is achieved by splitting the thyroid cartilage exactly in the midline (the thyroid notch) to gain direct access to the interior of the larynx, specifically the endolaryngeal structures like the vocal cords. * **Why Option A is correct:** The term "fissure" implies a split or opening. By incising the thyroid cartilage vertically in the midline, the surgeon can "hinge" the two halves of the larynx open, providing excellent exposure for the removal of benign or early malignant lesions. * **Why Option B is incorrect:** Making a "window" in the thyroid cartilage refers to a **Thyroplasty** (specifically Type I), used in phonosurgery to medialize a paralyzed vocal cord. * **Why Option C is incorrect:** Removal of the arytenoids is called an **Arytenoidectomy**, typically performed to widen the airway in cases of bilateral abductor vocal cord paralysis. * **Why Option D is incorrect:** Removal of the epiglottis is an **Epiglottidectomy**, often part of a supraglottic laryngectomy. **High-Yield Clinical Pearls for NEET-PG:** 1. **Indications:** Laryngofissure is primarily used for **Cordectomy** (removal of a vocal cord) in early T1 glottic carcinoma, removal of laryngeal webs, or access for laryngeal trauma repair. 2. **Anatomical Landmark:** The incision is made through the **Broyle’s ligament** (the attachment of the vocal cords to the thyroid cartilage), which is a weak point as it lacks perichondrium. 3. **Contraindication:** It is generally avoided if the tumor crosses the anterior commissure or involves the cartilage.

Q: Microlaryngoscopy is usually performed using an objective lens with what focal length?

400 mm. **Explanation:** Microlaryngoscopy (MLS) is a surgical procedure that utilizes an operating microscope to visualize the larynx with high magnification and illumination. **1. Why 400 mm is the Correct Answer:** The focal length of the objective lens determines the working distance between the lens and the surgical site. In microlaryngoscopy, the surgeon must accommodate the length of the **laryngoscope** (which is approximately 18–22 cm) while maintaining enough space to manipulate long microsurgical instruments (like forceps and scissors). A **400 mm (40 cm) lens** provides the optimal working distance, allowing the microscope to remain at a comfortable distance from the patient’s mouth while keeping the vocal folds in sharp focus. **2. Analysis of Incorrect Options:** * **100 mm & 200 mm:** These focal lengths are too short. A 200 mm lens is standard for **Otology (Ear surgery)** because the distance from the microscope to the tympanic membrane is much shorter. Using these for MLS would cause the microscope to hit the laryngoscope or the patient's face. * **300 mm:** While sometimes used in neurosurgery or pediatric ENT, it generally provides insufficient clearance for the standard long instruments used in adult microlaryngoscopy. **3. Clinical Pearls for NEET-PG:** * **Standard Lens for Ear Surgery:** 200 mm (High-yield contrast). * **Standard Lens for Laryngeal Surgery:** 400 mm. * **Positioning:** MLS is performed in the **Boyce’s position** (Barking dog position)—neck flexed and head extended—to align the oral, pharyngeal, and laryngeal axes. * **Ventilation:** Often performed via **Jet Ventilation** or a small-diameter microlaryngeal tube (MLT) to provide a better view of the posterior glottis.

Q: Which muscle is responsible for changing the pitch of the voice?

Cricothyroid. **Explanation:** The pitch of the voice is primarily determined by the **tension and length** of the vocal cords. **1. Why Cricothyroid is correct:** The **Cricothyroid** muscle is known as the **"Tuning Fork of the Larynx."** When it contracts, it tilts the thyroid cartilage forward or elevates the cricoid arch, thereby increasing the distance between the thyroid and arytenoid cartilages. This action stretches, elongates, and tenses the vocal folds. Increased tension leads to a higher frequency of vibration, which results in a **higher pitch**. **2. Why other options are incorrect:** * **Posterior cricoarytenoids (PCA):** These are the only **abductors** of the vocal cords (Safety muscle of the larynx). They open the glottis for respiration but do not primarily regulate pitch. * **Lateral cricoarytenoids (LCA):** These are the primary **adductors** of the vocal cords, bringing them together for phonation. * **Vocalis:** This is the medial part of the thyroarytenoid muscle. It is responsible for **fine-tuning** and shortening the vocal cords, which generally lowers the pitch or changes the quality of the tone, but the primary "pitch changer" remains the cricothyroid. **High-Yield Clinical Pearls for NEET-PG:** * **Nerve Supply:** All intrinsic muscles of the larynx are supplied by the **Recurrent Laryngeal Nerve (RLN)** EXCEPT the **Cricothyroid**, which is supplied by the **External Laryngeal Nerve**. * **External Laryngeal Nerve Injury:** Often occurs during Thyroidectomy (superior pole ligation). It results in a loss of high-pitched voice and easy vocal fatigue (the "monotone" voice). * **Safety Muscle:** Posterior Cricoarytenoid (PCA) is the only abductor; its paralysis leads to respiratory distress.

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.

Q: The "TURBAN" epiglottis is pathognomic of which condition?

Sarcoidosis. ### Explanation The correct answer is **Sarcoidosis**. **1. Why Sarcoidosis is Correct:** Laryngeal sarcoidosis occurs in approximately 1–5% of patients with systemic sarcoidosis. The disease typically involves the supraglottic structures, most notably the **epiglottis**. The underlying pathology involves non-caseating granulomatous infiltration, which causes the epiglottis to become pale, edematous, and massively thickened. This characteristic rounded, swollen appearance is classically described as a **"Turban-shaped" epiglottis**. Patients usually present with hoarseness, dysphagia, or airway obstruction rather than pain. **2. Analysis of Incorrect Options:** * **Wegener’s Granulomatosis (Granulomatosis with Polyangiitis):** This condition primarily affects the **subglottic** region (Subglottic Stenosis) rather than the epiglottis. It is characterized by necrotizing granulomas and vasculitis. * **Histoplasmosis:** Fungal infections of the larynx typically present with painful ulcerations, heaped-up mucosa, or "millet-seed" nodules. They do not produce the uniform turban-like swelling seen in sarcoidosis. * **Malignancy:** Laryngeal carcinoma (Squamous Cell Carcinoma) usually presents as an exophytic mass or an infiltrative ulcer. While it can cause swelling, it is typically asymmetric and associated with friability or vocal cord fixation. **3. High-Yield Clinical Pearls for NEET-PG:** * **Turban Epiglottis:** Sarcoidosis. * **Omega-shaped Epiglottis:** Laryngomalacia (most common cause of congenital stridor). * **Leaf-like/Normal Epiglottis:** Often seen in Laryngeal Tuberculosis (though TB can also cause a "pseudo-turban" appearance, Sarcoidosis is the classic textbook association for "Turban"). * **Cherry Red Epiglottis:** Acute Epiglottitis (caused by *H. influenzae*). * **Subglottic Stenosis:** Most common laryngeal manifestation of Wegener’s Granulomatosis.

Q: What is the most common cause of laryngeal stridor in a 60-year-old male?

Carcinoma of the larynx. **Explanation:** In an elderly male (60 years old), the most common cause of laryngeal stridor is **Carcinoma of the Larynx**. Stridor in this age group is considered a "red flag" symptom, often indicating a mechanical obstruction of the airway. Squamous cell carcinoma is the most frequent histological type, and risk factors like chronic smoking and alcohol consumption are highly prevalent in this demographic. The tumor causes narrowing of the glottic or subglottic space, leading to inspiratory or biphasic stridor. **Analysis of Incorrect Options:** * **Nasopharyngeal Carcinoma:** While common in certain demographics, it typically presents with nasal obstruction, epistaxis, or conductive hearing loss (due to Eustachian tube blockage). It does not cause laryngeal stridor unless there is massive secondary spread or cranial nerve involvement affecting the vocal cords, which is rare as an initial presentation. * **Thyroid Carcinoma:** This can cause stridor by extrinsic compression or direct invasion of the trachea/recurrent laryngeal nerve. However, statistically, primary laryngeal malignancy is a more frequent cause of intrinsic laryngeal obstruction in elderly males. * **Foreign Body Aspiration:** This is a leading cause of sudden-onset stridor in the **pediatric** population (1–3 years). In adults, it is less common and usually associated with neurological deficits or trauma. **Clinical Pearls for NEET-PG:** * **Most common cause of stridor in infants:** Laryngomalacia (characterized by inspiratory stridor that worsens when supine). * **Most common cause of acute stridor in children:** Acute Laryngotracheobronchitis (Croup). * **Rule of Thumb:** In any elderly patient presenting with hoarseness of voice for more than 3 weeks, Carcinoma of the Larynx must be ruled out via indirect laryngoscopy or 70-degree endoscopy.

Q: Bryce sign is seen in which of the following conditions?

Laryngomalacia. **Explanation:** **Laryngomalacia** is the most common congenital anomaly of the larynx and the leading cause of congenital stridor. It is characterized by an inward collapse of the supraglottic structures (epiglottis, aryepiglottic folds) during inspiration. **Bryce Sign** is a clinical finding specific to laryngomalacia. It refers to the **increase in the intensity of the inspiratory stridor** when the infant is placed in the **supine position** or when the neck is flexed. Conversely, the stridor typically improves when the infant is placed in the prone position or when the neck is extended. This occurs because the supine position allows gravity to further displace the lax supraglottic tissues into the airway. **Analysis of Incorrect Options:** * **Post-cricoid carcinoma:** This condition is associated with **Trotter’s triad** (conductive deafness, palatal paralysis, and trigeminal neuralgia) or the loss of laryngeal crepitus (Moure’s sign), but not Bryce sign. * **Down’s syndrome:** While children with Down’s syndrome have a higher incidence of airway issues like subglottic stenosis or macroglossia, Bryce sign is not a diagnostic feature of the syndrome itself. * **Acute tonsillitis:** Presents with odynophagia and fever. Physical findings include enlarged, hyperemic tonsils with exudates, but no positional stridor. **High-Yield Clinical Pearls for NEET-PG:** * **Omega-shaped epiglottis:** The classic endoscopic finding in laryngomalacia. * **Management:** Most cases (90%) resolve spontaneously by 18–24 months. Severe cases requiring surgery (supraglottoplasty) are indicated if there is failure to thrive or cor pulmonale. * **Stridor characteristics:** Inspiratory, high-pitched, and worsens with crying or feeding.

Q: What is seen after tracheostomy?

Decreased in dead space. **Explanation:** Tracheostomy is a surgical procedure that creates an opening in the trachea, bypassing the upper respiratory tract (nose, pharynx, and larynx). **Why "Decreased in dead space" is correct:** The primary physiological effect of a tracheostomy is the reduction of **anatomical dead space** by approximately **30% to 50%**. By bypassing the upper airway, the volume of air that does not participate in gas exchange is significantly reduced. This improves alveolar ventilation and reduces the work of breathing, which is particularly beneficial in patients with respiratory failure. **Analysis of Incorrect Options:** * **A & B (V/P Ratio):** The Ventilation/Perfusion (V/Q) ratio is primarily determined by pulmonary blood flow and alveolar ventilation at the capillary level. While tracheostomy improves ventilation, it does not inherently "invert" or predictably increase the ratio across the entire lung in a way that defines the procedure's primary physiological hallmark. * **D (Increased resistance):** Tracheostomy actually **decreases** airflow resistance. The upper airway (especially the nose and glottis) accounts for a large portion of total airway resistance. Bypassing these structures with a wider, shorter tube makes it easier for air to reach the lungs. **High-Yield Clinical Pearls for NEET-PG:** * **Dead Space Reduction:** Tracheostomy reduces dead space by ~150ml in adults. * **Indications:** Respiratory failure, upper airway obstruction (e.g., laryngeal edema, tumors), and protection of the tracheobronchial tree (e.g., bulbar palsy). * **Immediate Complication:** Hemorrhage (most common), Apnea (due to sudden washout of $CO_2$ in chronic retainers), and Pneumothorax. * **Late Complication:** Tracheal stenosis (most common at the site of the cuff or stoma).

Question 1

Direct bronchoscopy can visualize all except:

Accepted Answer

Subcarinal lymph nodes

Answer

Trachea

Answer

Vocal cords

Answer

First segmental subdivision of bronchus

Question 2

A laryngocele develops from which anatomical structure?

Accepted Answer

Ventricular saccule

Answer

Thyroid cartilage

Answer

Cricoid cartilage

Answer

Epiglottis

Question 3

What is laryngofissure?

Accepted Answer

Opening the larynx in the midline

Answer

Making a window in the thyroid cartilage

Answer

Removal of the arytenoids

Answer

Removal of the epiglottis

Question 4

Microlaryngoscopy is usually performed using an objective lens with what focal length?

Accepted Answer

400 mm

Answer

100 mm

Answer

200 mm

Answer

300 mm

Question 5

Which muscle is responsible for changing the pitch of the voice?

Accepted Answer

Cricothyroid

Answer

Posterior cricoarytenoids

Answer

Lateral cricoarytenoids

Answer

Vocalis

Question 6

Which drug is locally used for tracheal stenosis?

Accepted Answer

Mitomycin C

Answer

Doxorubicin

Answer

Bleomycin

Answer

Clindamycin

Question 7

The "TURBAN" epiglottis is pathognomic of which condition?

Accepted Answer

Sarcoidosis

Answer

Wegener's granulomatosis

Answer

Histoplasmosis

Answer

Malignancy

Question 8

What is the most common cause of laryngeal stridor in a 60-year-old male?

Accepted Answer

Carcinoma of the larynx

Answer

Nasopharyngeal carcinoma

Answer

Thyroid carcinoma

Answer

Foreign body aspiration

Question 9

Bryce sign is seen in which of the following conditions?

Accepted Answer

Laryngomalacia

Answer

Post cricoid carcinoma

Answer

Down's syndrome

Answer

Acute tonsillitis

Question 10

What is seen after tracheostomy?

Accepted Answer

Decreased in dead space

Answer

Inversion of V/P ratio

Answer

Increased V/P ratio

Answer

Increased resistance of air flow

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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