Diseases of the Larynx Practice Questions

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: Rienke's edema in the vocal cord is a condition affecting which layer?

Submucosal. **Explanation:** Reinke’s edema is a clinical condition characterized by the accumulation of gelatinous fluid in the **Reinke’s space**. To understand why the correct answer is the **submucosal layer**, one must look at the microanatomy of the vocal fold (Hirano’s Layer Structure). The vocal fold consists of five layers. The outermost is the stratified squamous epithelium (Mucosa). Immediately beneath this lies the **Lamina Propria**, which is divided into three parts: 1. **Superficial Layer (Reinke’s Space):** This is a potential space composed of loose areolar tissue. 2. **Intermediate Layer** 3. **Deep Layer** Reinke’s edema specifically involves the **Superficial Lamina Propria**, which is histologically part of the **submucosal** structure of the vocal cord. **Analysis of Options:** * **A. Mucosal:** While the epithelium covers the edema, the pathology (fluid accumulation) occurs beneath the basement membrane, not within the epithelial cells themselves. * **C. Muscular layer:** The Thyroarytenoid (vocalis) muscle lies deep to the lamina propria and is not involved in the edematous process of Reinke’s. * **D. All layers:** The condition is localized to the superficial lamina propria; it does not infiltrate the vocal ligament or the muscle. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Strongly associated with **chronic smoking** and vocal abuse (often seen in middle-aged women). * **Clinical Feature:** Presents with a characteristic **low-pitched, "husky" voice**. * **Appearance:** Bilateral, diffuse, "bag-like" swelling of the vocal cords. * **Treatment:** Smoking cessation is mandatory. Surgical management involves a "stringing" procedure or **decortication** (stripping of the vocal cord mucosa).

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: In a case of glottic carcinoma with fully mobile cords, what is the treatment of choice?

Radiotherapy. ### Explanation **1. Why Radiotherapy is the Correct Answer:** Glottic carcinoma with **fully mobile vocal cords** corresponds to **Stage T1** (limited to vocal cords) or **T2** (extension to supraglottis/subglottis with normal mobility). For early-stage glottic cancer (T1 and T2), the primary goal is **cure with organ preservation**. Radiotherapy (RT) is the treatment of choice because it offers excellent local control rates (85-95% for T1) while providing a **superior functional voice quality** compared to surgical options. In modern practice, Transoral Laser Microsurgery (TLM) is also an equivalent alternative, but RT remains the classic gold standard for preserving the mucosal wave of the vocal cord. **2. Why Other Options are Incorrect:** * **A. Total Laryngectomy:** This is reserved for advanced stages (T3 with fixed cords or T4a with cartilage destruction). It is far too radical for early disease where the larynx can be saved. * **C. Hemilaryngectomy:** This is a type of partial laryngectomy. While oncologically sound, it results in a poorer voice quality compared to RT and involves a more invasive surgical recovery. It is usually reserved for RT failures or specific anatomical contraindications. * **D. Chemotherapy:** Chemotherapy is not used as a standalone curative treatment for glottic cancer. It is typically used as "induction" or "concurrent" therapy with RT for organ preservation in advanced (Stage III/IV) cases. **3. High-Yield Clinical Pearls for NEET-PG:** * **Staging Key:** Mobile cords = T1/T2; Fixed cords = T3. * **Most Common Site:** The glottis is the most common site for laryngeal cancer (60-65%). * **Lymphatic Spread:** Glottic cancers have a **low rate of nodal metastasis** due to the sparse lymphatic drainage of the true vocal cords (Reinke’s space). * **Prognosis:** Glottic cancer has the best prognosis among all laryngeal cancers because it presents early with hoarseness.

Q: Which of the following is the gold standard test for Laryngopharyngeal Reflux?

24 hour double probe pH monitoring. **Explanation:** **Laryngopharyngeal Reflux (LPR)**, often called "silent reflux," occurs when gastric contents travel past the upper esophageal sphincter (UES) into the larynx and pharynx. Unlike GERD, LPR primarily affects the respiratory epithelium, which is highly sensitive to pepsin and acid. **Why Option A is Correct:** The **24-hour double-probe pH monitoring** is the **Gold Standard** for diagnosing LPR. It utilizes two sensors: one placed above the Lower Esophageal Sphincter (LES) and a second "proximal" probe placed in the hypopharynx (above the UES). This allows clinicians to confirm that acidic contents are actually reaching the laryngeal tissues, rather than just remaining in the esophagus. **Why Other Options are Incorrect:** * **Option B (Esophageal biopsy):** This is used to diagnose Barrett’s esophagus or eosinophilic esophagitis. It does not provide information about the retrograde flow of acid into the larynx. * **Option C (Barium Swallow):** While it can detect structural abnormalities (like strictures or hiatal hernia), it has very low sensitivity for detecting transient reflux episodes. * **Option D (Motility studies):** Manometry is used to diagnose primary esophageal motility disorders (like Achalasia cardia) but cannot confirm the presence of acid reflux. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom of LPR:** Globus pharyngeus (sensation of a lump in the throat). * **Most common sign on Laryngoscopy:** Interarytenoid erythema/pachydermia (thickening of the posterior commissure). * **Reflux Finding Score (RFS):** A clinical tool used during endoscopy to quantify LPR severity. * **Treatment:** LPR requires more aggressive and longer treatment than GERD (twice-daily PPIs for 3–6 months).

Q: In bilateral recurrent laryngeal nerve palsy, which of the following is seen?

Dyspnea and stridor with a normal voice. In **Bilateral Recurrent Laryngeal Nerve (RLN) Palsy**, both vocal cords typically assume a **median or paramedian position**. This occurs because the cricothyroid muscle (supplied by the Superior Laryngeal Nerve) remains intact and acts as an adductor, pulling the cords toward the midline. ### Why Option B is Correct: * **Dyspnea and Stridor:** Because both cords are fixed near the midline, the glottic airway is severely narrowed. This leads to significant inspiratory stridor and respiratory distress (dyspnea), often requiring an emergency tracheostomy. * **Normal Voice:** Since the vocal cords are closely approximated (adducted), they can still vibrate against each other effectively during phonation. Consequently, the patient’s voice often remains surprisingly good or near-normal. ### Why Other Options are Incorrect: * **Option A & D:** Hoarseness is characteristic of **unilateral** RLN palsy (where one cord cannot meet the other) or late-stage bilateral palsy. In acute bilateral palsy, the airway is the primary concern, not the voice quality. * **Option C:** Inhalation of food (aspiration) and a feeble voice are features of **Bilateral Combined Paralysis** (involving both RLN and Superior Laryngeal Nerves). In such cases, the cords are in the "cadaveric" position (further apart), leading to a total loss of glottic protection and inability to phonate. ### High-Yield Clinical Pearls for NEET-PG: * **Most common cause:** Thyroid surgery (iatrogenic injury). * **Semon’s Law:** States that in progressive lesions of the RLN, the abductor fibers are injured before the adductor fibers. * **Position of cords:** In isolated RLN palsy, cords are **paramedian**. In combined (RLN + SLN) palsy, cords are **cadaveric** (mid-abduction). * **Management:** Acute cases often require **tracheostomy**. Definitive surgical options include **Kashima’s operation** (posterior cordectomy) or Woodman’s medialization.

Q: After laryngectomy, from where is dynamic esophageal voice produced?

Pharynx and esophagus. **Explanation:** After a total laryngectomy, the natural sound source (the larynx) is removed, and the trachea is diverted to a permanent stoma. To regain speech, patients can learn **Esophageal Voice**, a technique where air is swallowed or "injected" into the upper esophagus and then expelled in a controlled manner. **Why Option B is correct:** The sound is produced at the **Pharyngoesophageal (PE) segment**, which acts as a "neoglottis." As air is expelled from the esophagus, it causes the mucosal folds of the **cricopharyngeal sphincter** and the lower **pharyngeal constrictors** to vibrate. Therefore, the voice is dynamically produced by the interaction between the **esophagus** (the air reservoir) and the **pharynx** (the vibratory source). **Why other options are incorrect:** * **A. Oral cavity:** The oral cavity acts as an articulator (forming words), but it cannot act as the primary sound generator. * **C. Trachea:** In a total laryngectomy, the trachea is physically disconnected from the pharynx/mouth. Air from the trachea exits through the stoma and cannot reach the mouth to produce esophageal voice. * **D. Pharynx:** While the pharyngeal muscles are involved in vibration, the esophagus is essential as the air reservoir. Option B is more comprehensive. **High-Yield Clinical Pearls for NEET-PG:** * **PE Segment:** The cricopharyngeus muscle is the most important component of the vibratory segment. * **Success Rate:** Esophageal speech is difficult to master; only about 25-30% of patients become fluent. * **Tracheoesophageal Puncture (TEP):** This is currently the "Gold Standard" for post-laryngectomy rehabilitation. It uses a one-way valve (e.g., Blom-Singer prosthesis) to divert tracheal air into the esophagus for better voice quality than simple esophageal speech. * **Electrolarynx:** An external device used by patients who cannot master TEP or esophageal speech.

Q: What is the antibiotic of choice in acute epiglottitis pending culture sensitivity reports?

Ampicillin. **Explanation:** **Acute Epiglottitis** is a life-threatening emergency characterized by rapid inflammation of the epiglottis and supraglottic structures. Historically, the most common causative organism is ***Haemophilus influenzae* type b (Hib)**. **1. Why Ampicillin is the Correct Choice:** In the context of standard textbooks (like Dhingra) and traditional NEET-PG patterns, **Ampicillin** is considered the drug of choice for empirical management. It is highly effective against *H. influenzae*, which is the primary pathogen. While many modern guidelines suggest third-generation cephalosporins (like Ceftriaxone) due to rising beta-lactamase resistance, Ampicillin remains the classic "textbook" answer for this condition in the absence of resistance data. **2. Analysis of Incorrect Options:** * **Erythromycin (A):** This is a macrolide primarily used for *Legionella*, *Mycoplasma*, or Diphtheria. It does not provide adequate coverage for the aggressive Gram-negative nature of *H. influenzae*. * **Rolitetracycline (B) & Doxycycline (C):** Tetracyclines are generally bacteriostatic and are not indicated for acute, life-threatening airway infections like epiglottitis. They are also contraindicated in children (the primary demographic) due to effects on bone and teeth. **3. Clinical Pearls for NEET-PG:** * **Cardinal Signs:** The "3 Ds" – **D**rooling, **D**yspnea, and **D**ysphagia. * **X-ray Finding:** Lateral neck X-ray shows the **"Thumb sign"** (swollen epiglottis). * **Management Priority:** The first priority is **airway maintenance** (intubation or tracheostomy). Never examine the throat with a tongue depressor as it can trigger fatal laryngospasm. * **Modern Trend:** If Ampicillin/Amoxicillin resistance is suspected, **Ceftriaxone** is the preferred modern alternative.

Question 1

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 2

Rienke's edema in the vocal cord is a condition affecting which layer?

Accepted Answer

Submucosal

Answer

Mucosal

Answer

Muscular layer

Answer

All layers

Question 3

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 4

In a case of glottic carcinoma with fully mobile cords, what is the treatment of choice?

Accepted Answer

Radiotherapy

Answer

Total laryngectomy

Answer

Hemilaryngectomy

Answer

Chemotherapy

Question 5

Which of the following is the gold standard test for Laryngopharyngeal Reflux?

Accepted Answer

24 hour double probe pH monitoring

Answer

Esophageal biopsy

Answer

Abnormal esophageal radiography (Barium Swallow)

Answer

Esophageal motility studies

Question 6

In bilateral recurrent laryngeal nerve palsy, which of the following is seen?

Accepted Answer

Dyspnea and stridor with a normal voice

Answer

Hoarseness, dyspnea, and stridor

Answer

Inhalation of food and a feeble voice

Answer

Hoarseness and dyspnea

Question 7

After laryngectomy, from where is dynamic esophageal voice produced?

Accepted Answer

Pharynx and esophagus

Answer

Oral cavity

Answer

Trachea

Answer

Pharynx

Question 8

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

Accepted Answer

Respiratory obstruction

Answer

Acidosis

Answer

Atelectasis

Answer

Laryngospasm

Question 9

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 10

What is the antibiotic of choice in acute epiglottitis pending culture sensitivity reports?

Accepted Answer

Ampicillin

Answer

Erythromycin

Answer

Rolitetracycline

Answer

Doxycycline

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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