Diseases of the Larynx — MCQs

Diseases of the Larynx Indian Medical PG Practice Questions and MCQs

Question 81: Injury to the superior laryngeal nerve causes which of the following?

A. Hoarseness
B. Paralysis of vocal cords
C. No effect
D. Loss of timbre of voice (Correct Answer)

Explanation: The **Superior Laryngeal Nerve (SLN)** divides into two branches: the internal laryngeal nerve (sensory) and the **external laryngeal nerve (motor)**. The external branch supplies the **cricothyroid muscle**, which is the only intrinsic muscle of the larynx located outside the laryngeal framework. ### Why "Loss of timbre of voice" is correct: The cricothyroid muscle acts as a **tensor of the vocal cords**. It tilts the thyroid cartilage forward, lengthening and tightening the cords to increase the pitch of the voice. Injury to the SLN leads to paralysis of the cricothyroid, resulting in a loss of tension. This manifests clinically as: * **Loss of timbre (quality)** and range of voice. * Inability to produce high-pitched sounds (common in singers). * Easy vocal fatigue. ### Why other options are incorrect: * **A & B: Hoarseness and Paralysis of vocal cords:** These are characteristic of **Recurrent Laryngeal Nerve (RLN)** injury. The RLN supplies all other intrinsic muscles of the larynx and is responsible for vocal cord abduction/adduction. SLN injury alone does not cause significant hoarseness or cord paralysis. * **C: No effect:** While the voice may sound normal during routine conversation, there is a distinct functional deficit in pitch control and vocal strength. ### High-Yield Clinical Pearls for NEET-PG: * **Internal Laryngeal Nerve Injury:** Leads to anesthesia of the laryngeal mucosa above the vocal cords, increasing the risk of **aspiration**. * **Combined SLN and RLN Injury:** Results in the vocal cord being in the **cadaveric position** (midway between abducted and adducted). * **Wagner and Grossman Theory:** Suggests that if the SLN is intact in an RLN palsy, the vocal cord remains in the paramedian position due to the adducting action of the cricothyroid.

Question 82: A 38-year-old man presents with stridor following a respiratory infection. Cotton's grading is used to classify the pathology. Which of the following is the diagnosis?

A. Subglottic stenosis (Correct Answer)
B. Laryngeal carcinoma
C. Superior laryngeal nerve palsy
D. Vocal cord misuse

Explanation: **Explanation:** **Subglottic stenosis** is the correct diagnosis because **Cotton’s Grading System** is the gold-standard classification specifically used to quantify the severity of subglottic stenosis. It is based on the percentage of luminal narrowing: * **Grade I:** <50% obstruction * **Grade II:** 51–70% obstruction * **Grade III:** 71–99% obstruction * **Grade IV:** Complete obstruction (no detectable lumen) In this clinical scenario, the patient presents with **stridor** (a hallmark of airway narrowing) following a respiratory infection, which can trigger inflammatory stenosis or exacerbate a pre-existing subclinical narrowing. **Analysis of Incorrect Options:** * **Laryngeal Carcinoma:** While it causes stridor, it is staged using the **TNM classification**, not Cotton’s grading. * **Superior Laryngeal Nerve Palsy:** This typically presents with voice fatigue or loss of high-pitched notes (due to cricothyroid muscle paralysis) rather than fixed airway stenosis. * **Vocal Cord Misuse:** This leads to functional voice disorders or organic lesions like vocal nodules, which are not graded by Cotton’s system. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Iatrogenic (prolonged endotracheal intubation) is the most common cause of acquired subglottic stenosis. * **Anatomical Site:** The subglottis is the narrowest part of the pediatric airway (at the level of the cricoid cartilage). * **Management:** Grade I and II are often managed conservatively or endoscopically (dilation/laser), while Grade III and IV usually require surgical reconstruction (Laryngotracheal reconstruction or Cricotracheal resection).

Question 83: Which of the following is NOT an indication for tracheostomy?

A. Flail chest
B. Respiratory distress in carcinoma of the larynx (Correct Answer)
C. Foreign body aspiration
D. Tetanus

Explanation: This question tests your understanding of the clinical indications for tracheostomy versus alternative airway management strategies. **Explanation of the Correct Answer:** The correct answer is **B (Respiratory distress in carcinoma of the larynx)**. While this sounds counterintuitive, the key lies in the clinical management of laryngeal cancer. In a patient with respiratory distress due to a laryngeal tumor, a tracheostomy is generally **avoided** if possible. Performing a tracheostomy through or near a tumor can lead to **"Stomal Recurrence,"** where cancer cells seed the tracheostomy site, significantly worsening the prognosis and complicating future definitive surgery (like a total laryngectomy). The preferred immediate management is **endotracheal intubation** or **debulking the tumor** (CO2 laser or microdebridement) to secure the airway until definitive surgery can be performed. **Analysis of Incorrect Options:** * **A. Flail Chest:** Tracheostomy is indicated to reduce "dead space," assist in bronchial toilet (clearing secretions), and facilitate long-term mechanical ventilation. * **C. Foreign Body Aspiration:** If a foreign body causes acute upper airway obstruction that cannot be bypassed or removed via bronchoscopy/Heimlich maneuver, an emergency tracheostomy (or cricothyroidotomy) is life-saving. * **D. Tetanus:** Tracheostomy is indicated to prevent aspiration during spasms, manage laryngeal spasms, and facilitate long-term ventilation required due to neuromuscular blockade. **NEET-PG High-Yield Pearls:** * **Stomal Recurrence:** The primary reason to avoid tracheostomy in laryngeal CA. If unavoidable, the incision should be made as low as possible. * **Dead Space:** Tracheostomy reduces anatomical dead space by **30-50%**, making it vital in patients with poor respiratory reserve (e.g., Flail chest, COPD). * **Emergency Airway:** In an absolute emergency (cannot intubate, cannot ventilate), **Cricothyroidotomy** is the procedure of choice over tracheostomy due to speed and ease of access.

Question 84: A Blom-Singer prosthesis is used for voice rehabilitation following which surgical procedure?

A. Total laryngectomy (Correct Answer)
B. Near total laryngectomy
C. Hemi laryngectomy
D. None of the above

Explanation: **Explanation:** The **Blom-Singer prosthesis** is a one-way silicone valve used for **Tracheoesophageal Puncture (TEP)** speech, which is currently the "gold standard" for voice rehabilitation following a **Total Laryngectomy**. **Why Total Laryngectomy is correct:** In a total laryngectomy, the entire larynx is removed, and the trachea is diverted to a permanent stoma in the neck, completely separating the airway from the food pipe (esophagus). This results in a loss of natural phonation. The Blom-Singer prosthesis is inserted into a surgically created fistula between the posterior wall of the trachea and the anterior wall of the esophagus. When the patient occludes the stoma and exhales, air is diverted through the valve into the esophagus, causing the pharyngoesophageal segment to vibrate and produce **esophageal speech**. **Why other options are incorrect:** * **Near-total laryngectomy:** This procedure preserves a small strip of endolaryngeal mucosa (a "shunt") that allows for spontaneous voice production without the need for a prosthetic valve. * **Hemi-laryngectomy:** This is a partial laryngectomy where only one vocal cord is removed. The patient retains a functional airway and the ability to speak using the remaining laryngeal structures, so a prosthesis is not required. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** It is a **one-way valve**; it allows air to move from the trachea to the esophagus but prevents food/liquid from entering the trachea (aspiration). * **Primary vs. Secondary TEP:** The prosthesis can be placed during the initial surgery (Primary) or weeks later (Secondary). * **Common Complication:** The most common reason for prosthesis failure/leakage is **fungal (Candida) colonization** or widening of the TEP tract. * **Other Voice Options:** Other methods post-laryngectomy include the **Electrolarynx** (external device) and traditional **Esophageal Speech** (burping air).

Question 85: Congenital laryngeal stridor is also known as:

A. Laryngomalacia (Correct Answer)
B. Quinsy
C. Laryngotracheobronchitis
D. Laryngeal web

Explanation: **Explanation:** **Laryngomalacia** is the most common congenital anomaly of the larynx and the most frequent cause of **congenital laryngeal stridor**. It is characterized by an inward collapse of the supraglottic structures (epiglottis, aryepiglottic folds) during inspiration due to abnormal flaccidity. This results in a characteristic high-pitched, inspiratory stridor that typically appears within the first two weeks of life, worsens with crying or feeding, and improves when the infant is placed in a prone position. **Analysis of Incorrect Options:** * **Quinsy (Peritonsillar Abscess):** An acute complication of tonsillitis involving a collection of pus between the tonsillar capsule and the pharyngeal constrictor muscle. It is an acquired infection, not a congenital condition. * **Laryngotracheobronchitis (Croup):** An acute viral infection of the upper airway causing subglottic edema. It typically presents in older infants (6 months to 3 years) with a "barking" cough and inspiratory stridor. * **Laryngeal Web:** A congenital or acquired condition where a bridge of tissue spans the vocal cords. While it causes stridor, it is much rarer than laryngomalacia and is typically associated with a weak or muffled cry from birth. **High-Yield Clinical Pearls for NEET-PG:** * **Omega-shaped epiglottis:** The classic endoscopic finding in laryngomalacia. * **Diagnosis:** Confirmed by flexible fiberoptic laryngoscopy (showing collapse of supraglottic tissues). * **Management:** Most cases (90%) are self-limiting and resolve by 18–24 months as the laryngeal cartilage matures. Severe cases with failure to thrive or cyanosis require **supraglottoplasty**.

Question 86: Which substance is associated with minimal tissue reaction in injection laryngoplasty?

A. Fat
B. Gelfoam
C. Calcium hydroxyapatite (Correct Answer)
D. Bioplastique

Explanation: **Explanation:** Injection laryngoplasty is a procedure used to medialize a paralyzed or atrophic vocal cord to improve voice quality and airway protection. The ideal injectable material should be biocompatible, non-immunogenic, and cause minimal inflammatory response. **Why Calcium Hydroxyapatite (CaHA) is correct:** Calcium hydroxyapatite (e.g., Radiesse Voice) is a constituent of bone and teeth, making it highly **biocompatible**. It consists of microspheres suspended in a carboxymethylcellulose carrier. It is considered the "gold standard" for long-term augmentation because it produces **minimal tissue reaction** and provides excellent structural support. Over time, the gel carrier is absorbed, and the microspheres remain, often stimulating minimal fibrovascular ingrowth without significant inflammation. **Analysis of Incorrect Options:** * **Fat (Autologous):** While biocompatible, harvesting requires a donor site. Its main disadvantage is an **unpredictable resorption rate** (30-60%), often requiring over-correction. * **Gelfoam:** This is a temporary material (lasting 4–6 weeks). While safe, it is primarily used for trial medialization or temporary paralysis and does not offer the long-term stability or the specific inert profile of CaHA. * **Bioplastique:** This is a permanent material consisting of solid silicone particles. It is known to cause a **significant foreign body giant cell reaction** and granuloma formation, making it less favorable than CaHA. **High-Yield Clinical Pearls for NEET-PG:** * **Temporary materials:** Gelfoam, Hyaluronic acid, Collagen (used when recovery of nerve function is expected). * **Long-term/Permanent materials:** Calcium Hydroxyapatite, Teflon (Teflon is now largely abandoned due to "Teflon granuloma" formation). * **Injection Site:** Materials are typically injected lateral to the vocal fold into the **thyroarytenoid muscle** or the paraglottic space; injection into the Reinke’s space must be avoided to prevent stiffness.

Question 87: The Myer-Cotton grading system is used for:

A. Subglottic stenosis (Correct Answer)
B. Tonsillitis
C. Sinusitis
D. None of the above

Explanation: The **Myer-Cotton grading system** is the gold standard for clinically classifying the severity of **Subglottic Stenosis (SGS)**. It is based on the percentage of luminal cross-sectional area reduction, typically assessed using endotracheal tubes of different sizes during endoscopy. ### Why the Correct Answer is Right: The system categorizes subglottic stenosis into four grades to guide surgical management: * **Grade I:** < 50% obstruction. * **Grade II:** 51% to 70% obstruction. * **Grade III:** 71% to 99% obstruction (identifiable lumen present). * **Grade IV:** 100% obstruction (no detectable lumen/complete atresia). ### Why Other Options are Wrong: * **Tonsillitis:** Severity is usually graded using the **Brodsky Scale** (1+ to 4+), which measures how much the tonsils occupy the oropharyngeal airway. * **Sinusitis:** Diagnosis and staging are primarily radiological (CT scan) using the **Lund-Mackay scoring system**, or clinical based on duration (Acute vs. Chronic). ### High-Yield Clinical Pearls for NEET-PG: * **McCaffrey System:** Another classification for laryngotracheal stenosis, but it focuses on the **site and length** of the lesion rather than just the percentage of obstruction. * **Most Common Cause:** The most common cause of acquired subglottic stenosis is **prolonged endotracheal intubation**. * **Anatomy:** The subglottis is the narrowest part of the pediatric airway (at the level of the cricoid cartilage), making it highly susceptible to stenosis. * **Management:** Grades I and II are often managed conservatively or endoscopically; Grades III and IV usually require reconstructive surgery (e.g., Laryngotracheal Reconstruction or Cricotracheal Resection).

Question 88: Regarding juvenile papillomas, which of the following statements is/are true?

A. Multiple, Seen in children, Recurrent
B. Single, Multiple, Seen in children
C. Multiple, Seen in children, Recurrent, Associated with HPV (Correct Answer)
D. Single, Seen in children, Recurrent, Associated with HPV

Explanation: **Explanation:** Juvenile-onset Recurrent Respiratory Papillomatosis (JORRP) is the most common benign neoplasm of the larynx in children. The correct answer is **C** because it accurately captures the four hallmark characteristics of the disease: 1. **Multiple:** Unlike the adult form (which is often a single pedunculated lesion), juvenile papillomas are typically **multicentric** and sessile, involving the true vocal cords, false cords, and epiglottis. 2. **Seen in children:** It usually presents between ages 2 and 5. Transmission is thought to occur during childbirth through an infected birth canal. 3. **Recurrent:** These tumors are notorious for their aggressive recurrence after surgical excision, often requiring multiple procedures. 4. **Associated with HPV:** It is caused by **Human Papillomavirus (HPV) types 6 and 11**. **Analysis of Incorrect Options:** * **Options B & D:** These are incorrect because juvenile papillomas are rarely "single." A single papilloma is characteristic of the **Adult-onset** variety, which is usually solitary and has a lower rate of recurrence. * **Option A:** While these descriptors are correct, they are incomplete. In NEET-PG, the most comprehensive option that includes the viral etiology (HPV) is the preferred answer. **Clinical Pearls for NEET-PG:** * **Most common site:** True vocal cords. * **Presenting symptom:** Hoarseness of voice (most common) or stridor. * **Treatment of choice:** CO2 Laser excision or Microdebridement. * **Adjuvant therapy:** Cidofovir (antiviral) is used in severe, rapidly recurring cases. * **Malignant transformation:** Rare, but can occur (usually to Squamous Cell Carcinoma), especially if associated with HPV-16 or 18.

Question 89: Indirect laryngoscopy is primarily used to visualize what anatomical structure?

A. Vocal Cords (Correct Answer)
B. Epiglottis
C. Bronchi
D. Trachea

Explanation: **Explanation:** **Indirect Laryngoscopy (IDL)** is a fundamental clinical procedure in ENT used to visualize the interior of the larynx. It is performed using a laryngeal mirror and a head mirror/lamp. **Why Vocal Cords is the Correct Answer:** The primary objective of IDL is to assess the **vocal cords** (true vocal folds) for their color, surface regularity, and, most importantly, their **mobility**. By asking the patient to phonate (say "eee"), the clinician can observe the adduction and abduction of the cords, making it the gold standard bedside test for diagnosing vocal cord paralysis, nodules, or malignancies. **Analysis of Incorrect Options:** * **B. Epiglottis:** While the epiglottis is visible during IDL, it is considered a "landmark" rather than the primary structure of interest. The procedure is specifically designed to look *past* the epiglottis into the glottis. * **C. Bronchi:** These are lower airway structures. Visualizing the bronchi requires **Bronchoscopy** (flexible or rigid), as they are located far below the laryngeal inlet. * **D. Trachea:** Only the uppermost part of the trachea may be visible during IDL. Detailed examination of the trachea requires **Direct Laryngoscopy** or **Tracheoscopy**. **NEET-PG High-Yield Pearls:** * **Mirror Image:** The image seen in IDL is **inverted** (anteroposteriorly) but not reversed laterally. The anterior commissure appears at the top of the mirror. * **Nerve Assessment:** IDL is the first-line investigation to check for **Recurrent Laryngeal Nerve (RLN)** palsy. * **Positioning:** It is performed in the **"Sniffing position"** (extension at atlanto-occipital joint and flexion at lower cervical spine). * **Structures seen:** Base of tongue, vallecula, epiglottis, aryepiglottic folds, arytenoids, ventricular bands (false cords), vocal cords, and pyriform fossae.

Question 90: A 64-year-old female develops chronic lung disease requiring intubation in the ICU for an 8-week period following a respiratory tract infection. Tracheal stenosis is noted. What is the most likely cause of tracheal stenosis?

A. Prolonged intubation (Correct Answer)
B. Tuberculosis
C. Scleroderma
D. Riedel struma (fibrous thyroiditis)

Explanation: ### Explanation **1. Why Prolonged Intubation is Correct:** The most common cause of acquired tracheal stenosis in clinical practice is **prolonged endotracheal intubation**. In this patient, the 8-week duration far exceeds the safe threshold (usually 7–14 days). The pathophysiology involves the pressure exerted by the endotracheal tube cuff against the tracheal mucosa. When this pressure exceeds the capillary perfusion pressure (approx. 30 mmHg), it leads to mucosal ischemia, ulceration, and necrosis. Subsequent healing occurs via secondary intention, leading to circumferential **fibrosis and cicatricial contraction**, resulting in stenosis. **2. Why the Other Options are Incorrect:** * **Tuberculosis (B):** While TB can cause endobronchial or tracheal stenosis through granulomatous inflammation, it is far less common than post-intubation trauma in an ICU setting. * **Scleroderma (C):** This is a systemic connective tissue disorder primarily affecting the esophagus (dysmotility) and lungs (interstitial lung disease), but it does not typically cause primary tracheal stenosis. * **Riedel Struma (D):** This is a rare form of thyroiditis where dense fibrous tissue replaces the thyroid gland and may invade adjacent structures. While it can cause extrinsic compression of the trachea, it rarely causes intrinsic tracheal stenosis. **3. Clinical Pearls for NEET-PG:** * **Site of Stenosis:** In intubated patients, stenosis most commonly occurs at the **cuff site**. In patients with a tracheostomy, it occurs at the **stoma site**. * **Prevention:** To prevent ischemia, cuff pressure should be maintained between **20–30 cm H₂O**. * **Management:** Small segments (<1 cm) may be treated with dilatation or laser; however, the gold standard for significant stenosis is **sleeve resection and end-to-end anastomosis**. * **Presentation:** Patients often present with "unexplained" dyspnea or stridor weeks after being discharged from the ICU.

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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