Diseases of the Larynx Practice Questions

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: A 6-month-old baby presents with loud, noisy breathing since birth, particularly noticeable when feeding in a supine position. The birth history is otherwise unremarkable. What is the recommended management for this condition?

Reassurance. ### Explanation **Diagnosis: Laryngomalacia** The clinical presentation describes **Laryngomalacia**, the most common cause of congenital stridor in infants. It is characterized by an inspiratory "crowing" sound (stridor) caused by the collapse of supraglottic structures (e.g., omega-shaped epiglottis) during inspiration. The stridor typically worsens when the infant is **supine**, crying, or feeding, and improves when prone. **Why Reassurance is Correct:** In more than 90% of cases, laryngomalacia is a self-limiting condition. The stridor usually peaks at 6 months and resolves spontaneously by 18–24 months as the airway cartilage matures and strengthens. Unless there is evidence of "danger signs" (failure to thrive, cyanosis, or severe respiratory distress), the standard management is **conservative observation and reassurance** to the parents. **Why Other Options are Incorrect:** * **A. 3rd generation cephalosporins:** These are used for bacterial infections like Epiglottitis. Laryngomalacia is a structural/developmental anomaly, not an infection. * **B. Heimlich’s maneuver:** This is an emergency intervention for acute foreign body airway obstruction, which would present with sudden onset choking, not a chronic sound present since birth. * **D. Single dose of Dexamethasone:** Steroids are the mainstay for **Croup (Laryngotracheobronchitis)** to reduce subglottic edema. They have no role in treating the structural collapse seen in laryngomalacia. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of inspiratory stridor in neonates:** Laryngomalacia. * **Classic finding on laryngoscopy:** "Omega-shaped" (Ω) epiglottis with short aryepiglottic folds. * **Definitive Diagnosis:** Flexible fiberoptic laryngoscopy (showing inward collapse of supraglottic tissues). * **Surgical Indication:** If severe (cor pulmonale, apnea, or poor weight gain), the procedure of choice is **Supraglottoplasty**.

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).

Q: Which laser is used in laryngeal work?

CO2. **Explanation:** The **CO2 (Carbon Dioxide) laser** is the gold standard and most commonly used laser in laryngeal surgery. Its wavelength (10,600 nm) is highly absorbed by water, which constitutes the majority of soft tissue. This results in **excellent precision, minimal peripheral thermal damage (0.1 mm), and superior hemostasis** for small vessels. In laryngeal work, it is used for procedures like cordectomy, papilloma excision, and treating subglottic stenosis because it allows for "what you see is what you get" surgical accuracy, preserving the delicate vocal cord architecture. **Analysis of Incorrect Options:** * **Argon Laser:** Primarily used in otology (e.g., stapedotomy) and ophthalmology. It is absorbed by pigment (hemoglobin/melanin) rather than water, making it less ideal for general laryngeal tissue ablation. * **Nd:YAG Laser:** It has deep tissue penetration (up to 4-5 mm), which causes significant collateral thermal damage. While used for debulking large obstructing tracheobronchial tumors, it lacks the precision required for delicate laryngeal surgery. * **Holmium Laser:** Mainly used in urology (lithotripsy) and orthopedic surgery. It is rarely used in the larynx due to its pulsed nature and less predictable tissue interaction compared to CO2. **High-Yield Clinical Pearls for NEET-PG:** * **KTP (Potassium Titanyl Phosphate) Laser:** Known as the "vascular laser," it is excellent for angiolytic work (e.g., vocal cord varices or papillomas) as it is absorbed by hemoglobin. * **Safety Protocol:** When using CO2 lasers in the airway, **Laser-safe endotracheal tubes** (e.g., Mallinckrodt or Medtronic) must be used, and the cuff should be filled with **saline dyed with methylene blue** to detect accidental perforation immediately. * **Mode of Delivery:** CO2 lasers are typically delivered via a micromanipulator attached to an operating microscope.

Q: Reinke's space is seen in which of the following anatomical locations?

Vocal cords. **Explanation:** **Reinke’s space** is a potential subepithelial space located in the **vocal cords** (specifically the true vocal folds). It is situated between the overlying non-keratinizing squamous epithelium and the underlying vocal ligament. 1. **Why Vocal Cords are correct:** Reinke’s space contains loose areolar tissue and lacks lymphatic drainage. This anatomical peculiarity is why fluid accumulation occurs easily here, leading to **Reinke’s Edema**. This space is bounded superiorly and inferiorly by the line of arcuate and anteriorly by the anterior commissure. 2. **Why other options are incorrect:** * **Subglottis:** This region starts below the vocal folds. It is characterized by respiratory epithelium and does not contain the specific loose connective tissue layer of Reinke. * **Epiglottis:** The epiglottis consists of elastic cartilage covered by a mucous membrane; it does not possess the specialized layered architecture of the true vocal folds. * **Pharynx:** The pharyngeal walls consist of mucosa, submucosa, and muscle layers, lacking the distinct "space" required for vocal fold vibration. **Clinical Pearls for NEET-PG:** * **Reinke’s Edema:** Characteristically seen in **chronic smokers** and those with **vocal abuse**. It presents with a low-pitched, gravelly voice. * **Lymphatics:** Reinke’s space has **no lymphatics**, which is why early glottic (vocal cord) cancers have an excellent prognosis as they do not spread to lymph nodes early. * **Histology:** The vocal fold has five layers. Reinke’s space corresponds to the **superficial layer of the lamina propria**.

Q: Cadeveric position of vocal cords after thyroidectomy is typically due to which of the following?

Bilateral recurrent laryngeal nerve paralysis.. **Explanation:** The position of the vocal cords is determined by the balance of intrinsic laryngeal muscles. In **Bilateral Recurrent Laryngeal Nerve (RLN) paralysis**, all intrinsic muscles of the larynx are paralyzed except for the cricothyroid (supplied by the external laryngeal nerve). The cricothyroid acts as a tensor and slight adductor. When both RLNs are severed (often during extensive thyroid surgery), the cords lose their motor supply and assume the **cadaveric position**—a neutral, mid-abducted position (approx. 3.5mm from the midline) where they are neither fully open nor closed. **Analysis of Options:** * **Option A (Unilateral RLN paralysis):** The affected cord typically assumes a **paramedian position** (1.5mm from midline) because the intact cricothyroid muscle on the same side adducts it slightly. The patient presents with hoarseness but a safe airway. * **Option C & D (External Laryngeal Nerve paralysis):** This nerve supplies the cricothyroid muscle. Paralysis leads to a loss of tension in the vocal cords, resulting in a **wavy/zigzag appearance** and inability to produce high-pitched sounds, but does not result in a cadaveric position. **NEET-PG High-Yield Pearls:** 1. **Semon’s Law:** States that in progressive RLN lesions, abductor fibers (posterior cricoarytenoid) are more vulnerable and paralyzed before adductor fibers. 2. **Wagner and Grossman Hypothesis:** Explains that if the Superior Laryngeal Nerve is intact, the cricothyroid muscle keeps the paralyzed cord in a paramedian position; if both SLN and RLN are gone, the cord moves to the cadaveric position. 3. **Clinical Emergency:** Bilateral RLN injury is a surgical emergency because the cords may eventually fall into a paramedian position, causing acute airway obstruction (stridor) requiring tracheostomy.

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: What is the most widely used treatment for recurrent respiratory papillomatosis?

CO2 laser ablation. **Explanation:** **Recurrent Respiratory Papillomatosis (RRP)** is a condition caused by Human Papillomavirus (HPV types 6 and 11), characterized by benign wart-like growths in the airway. The primary goal of treatment is to maintain a patent airway and improve voice quality while minimizing scarring. **Why CO2 Laser Ablation is correct:** The **CO2 laser** is considered the gold standard and most widely used treatment. Its wavelength is highly absorbed by water, allowing for precise, bloodless excision with minimal collateral thermal damage. This precision is vital in the larynx to prevent complications like anterior glottic webbing or permanent vocal cord scarring. **Analysis of Incorrect Options:** * **Diathermy excision:** This method involves significant thermal spread, which leads to excessive scarring and stenosis of the delicate laryngeal tissues. It is rarely used today. * **Excision with microdebrider:** While the microdebrider is a popular alternative (often preferred by some surgeons for faster removal and less thermal risk), the **CO2 laser remains the most "widely used" and classically cited** treatment in standard textbooks for NEET-PG. * **Wait for spontaneous resolution:** RRP is aggressive and can cause life-threatening airway obstruction. While juvenile-onset RRP may regress after puberty, active management is mandatory to prevent asphyxia. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** HPV 6 (most common) and HPV 11 (more aggressive). * **Most common site:** True vocal cords (squamous epithelium). * **Triad of symptoms:** Hoarseness, stridor, and respiratory distress. * **Adjuvant therapy:** Cidofovir (antiviral) is the most common adjuvant used for severe, rapidly recurring cases. * **Tracheostomy:** Should be avoided if possible, as it can lead to "stomal seeding" and distal spread of the disease into the lungs.

Question 1

The "TURBAN" epiglottis is pathognomic of which condition?

Accepted Answer

Sarcoidosis

Answer

Wegener's granulomatosis

Answer

Histoplasmosis

Answer

Malignancy

Question 2

A 6-month-old baby presents with loud, noisy breathing since birth, particularly noticeable when feeding in a supine position. The birth history is otherwise unremarkable. What is the recommended management for this condition?

Accepted Answer

Reassurance

Answer

3rd generation cephalosporins

Answer

Heimlich's maneuver

Answer

Single dose of Dexamethasone

Question 3

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

Question 4

Which laser is used in laryngeal work?

Accepted Answer

CO2

Answer

Argon

Answer

Nd:Yag

Answer

Holmium

Question 5

Reinke's space is seen in which of the following anatomical locations?

Accepted Answer

Vocal cords

Answer

Subglottis

Answer

Epiglottis

Answer

Pharynx

Question 6

Cadeveric position of vocal cords after thyroidectomy is typically due to which of the following?

Accepted Answer

Bilateral recurrent laryngeal nerve paralysis.

Answer

Unilateral recurrent laryngeal nerve paralysis.

Answer

Unilateral external laryngeal nerve paralysis.

Answer

Bilateral external laryngeal nerve paralysis.

Question 7

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 8

What is the most widely used treatment for recurrent respiratory papillomatosis?

Accepted Answer

CO2 laser ablation

Answer

Diathermy excision

Answer

Excision with microdebrider

Answer

Wait for spontaneous resolution

Question 9

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

Accepted Answer

Respiratory obstruction

Answer

Acidosis

Answer

Atelectasis

Answer

Laryngospasm

Question 10

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

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

On this page

Practice by Chapter

Want unlimited practice?