Diseases of the Larynx Practice Questions

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

Loss of timbre of voice. 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.

Q: 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?

Subglottic stenosis. **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).

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

Total laryngectomy. **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).

Q: Congenital laryngeal stridor is also known as:

Laryngomalacia. **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**.

Q: The Myer-Cotton grading system is used for:

Subglottic stenosis. 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).

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

Multiple, Seen in children, Recurrent, Associated with HPV. **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.

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

Vocal Cords. **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 1

Injury to the superior laryngeal nerve causes which of the following?

Accepted Answer

Loss of timbre of voice

Answer

Hoarseness

Answer

Paralysis of vocal cords

Answer

No effect

Question 2

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?

Accepted Answer

Subglottic stenosis

Answer

Laryngeal carcinoma

Answer

Superior laryngeal nerve palsy

Answer

Vocal cord misuse

Question 3

Which of the following is NOT an indication for tracheostomy?

Accepted Answer

Respiratory distress in carcinoma of the larynx

Answer

Flail chest

Answer

Foreign body aspiration

Answer

Tetanus

Question 4

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

Accepted Answer

Total laryngectomy

Answer

Near total laryngectomy

Answer

Hemi laryngectomy

Answer

None of the above

Question 5

Congenital laryngeal stridor is also known as:

Accepted Answer

Laryngomalacia

Answer

Quinsy

Answer

Laryngotracheobronchitis

Answer

Laryngeal web

Question 6

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

Accepted Answer

Calcium hydroxyapatite

Answer

Fat

Answer

Gelfoam

Answer

Bioplastique

Question 7

The Myer-Cotton grading system is used for:

Accepted Answer

Subglottic stenosis

Answer

Tonsillitis

Answer

Sinusitis

Answer

None of the above

Question 8

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

Accepted Answer

Multiple, Seen in children, Recurrent, Associated with HPV

Answer

Multiple, Seen in children, Recurrent

Answer

Single, Multiple, Seen in children

Answer

Single, Seen in children, Recurrent, Associated with HPV

Question 9

Indirect laryngoscopy is primarily used to visualize what anatomical structure?

Accepted Answer

Vocal Cords

Answer

Epiglottis

Answer

Bronchi

Answer

Trachea

Question 10

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?

Accepted Answer

Prolonged intubation

Answer

Tuberculosis

Answer

Scleroderma

Answer

Riedel struma (fibrous thyroiditis)

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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