Diseases of the Larynx Practice Questions

Q: All of the following conditions affect the posterior part of the larynx except?

Lupus. **Explanation:** The larynx is anatomically divided into anterior and posterior segments, each prone to specific pathologies based on the underlying tissue type (cartilaginous vs. membranous). **Why Lupus is the correct answer:** Lupus (Laryngeal Lupus) is a chronic granulomatous condition that characteristically involves the **anterior part** of the larynx. It most commonly affects the **epiglottis** (often leading to a "turban-shaped" epiglottis or destruction of the free edge) and the **vestibule**. Unlike other granulomatous diseases like Tuberculosis, Lupus is relatively painless and does not typically involve the posterior glottis. **Analysis of incorrect options (Posterior Laryngeal involvement):** * **Contact Ulcer:** Occurs due to mechanical trauma (vocal abuse) or LPR (Laryngopharyngeal Reflux). It specifically affects the **vocal process of the arytenoid cartilage**, which is located posteriorly. * **Pachydermia Laryngis:** A form of chronic hypertrophic laryngitis characterized by epithelial thickening. It classically involves the **interarytenoid notch** and the posterior third of the vocal cords. * **Intubation Granuloma:** This is a post-traumatic granuloma caused by the pressure of an endotracheal tube. Since the tube rests against the **posterior glottis** (vocal processes of arytenoids), the granuloma forms in this posterior location. **NEET-PG High-Yield Pearls:** * **Posterior Larynx Pathologies:** Contact ulcer, Pachydermia, Intubation granuloma, and **Tuberculosis** (TB classically affects the posterior part, presenting as a "mouse-nibbled" appearance). * **Anterior Larynx Pathologies:** Lupus, Laryngeal webs, and most Carcinomas (typically involve the anterior two-thirds of the membranous cord). * **Laryngeal Lupus vs. TB:** TB is painful and posterior; Lupus is painless and anterior.

Q: Which of the following could be an indication for performing a high tracheostomy in a middle-aged man?

Carcinoma. **Explanation:** Tracheostomy is classified based on its relationship to the thyroid isthmus: **High** (above the isthmus/1st ring), **Mid** (behind the isthmus/2nd-3rd rings), and **Low** (below the isthmus/4th-5th rings). **Why Carcinoma is correct:** In cases of **Carcinoma of the Larynx**, a high tracheostomy is indicated as a preliminary step before a **Total Laryngectomy**. Since the entire larynx and the first tracheal ring are to be removed during the definitive surgery, the high position of the stoma does not pose a long-term risk of perichondritis or subglottic stenosis, as those structures will be excised. **Why the other options are incorrect:** * **Tuberculosis, Tetanus, and Diphtheria:** These are inflammatory or infective conditions where the tracheostomy is intended to be temporary. In such cases, a **High Tracheostomy is strictly contraindicated** because the proximity of the tube to the cricoid cartilage leads to perichondritis and subsequent **subglottic stenosis**, making decannulation difficult. For these conditions, a Mid or Low tracheostomy is preferred. **High-Yield Clinical Pearls for NEET-PG:** * **Standard Choice:** Mid-tracheostomy is the most common procedure performed. * **Emergency:** In a dire emergency where a tracheostomy cannot be done, **Cricothyroidotomy** is the procedure of choice. * **Order of Incision:** For a routine tracheostomy, a vertical or transverse skin incision is followed by a **vertical incision** in the trachea (2nd and 3rd rings). * **Avoid:** Never divide the 1st tracheal ring to prevent subglottic stenosis.

Q: Reinke's edema is typically seen in which part of the larynx?

Edges of vocal cords. **Explanation:** **Reinke’s Edema** is a clinical condition characterized by the accumulation of gelatinous fluid in the **Reinke’s space**. This space is a potential subepithelial space located between the vocal ligament and the overlying squamous epithelium of the **true vocal cords**. 1. **Why Option A is Correct:** The Reinke’s space is anatomically restricted to the **edges of the vocal cords**. It lacks lymphatic drainage, which predisposes it to fluid accumulation when subjected to chronic irritation (most commonly **smoking** and **vocal abuse**). This results in a "baggy," polypoid appearance of the vocal folds. 2. **Why Other Options are Incorrect:** * **Vestibular folds (False Cords):** These are located superior to the true vocal cords and do not contain Reinke’s space; they are rarely involved in localized edema of this nature. * **Between true and false vocal cords:** This area is the **Laryngeal Ventricle (Sinus of Morgagni)**. While pathologies like laryngoceles occur here, Reinke’s edema is specific to the cord margins. * **Pyriform fossa:** This is a part of the **hypopharynx**, not the larynx. It is a common site for foreign bodies and malignancies, but not Reinke’s edema. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Strongly associated with **heavy smoking** and chronic voice strain. * **Clinical Presentation:** Typically presents as a **low-pitched, hoarse voice** (often described as a "manly voice" in females). * **Treatment:** Smoking cessation is mandatory. Definitive treatment involves **decortication** of the vocal cord (stripping the mucosa) using a "microflap" technique. * **Histology:** Shows loose stroma, edema, and dilated capillaries.

Q: Bilateral recurrent laryngeal nerve palsy is most commonly associated with which of the following conditions?

Thyroid surgery. **Explanation:** The **Recurrent Laryngeal Nerve (RLN)** is the most common nerve injured during neck surgeries due to its intimate anatomical relationship with the inferior thyroid artery and the posterior capsule of the thyroid gland. **1. Why Thyroid Surgery is Correct:** Thyroidectomy (especially total thyroidectomy) is the leading cause of **bilateral** RLN palsy. During the procedure, the nerves can be damaged via transection, clamping, traction, or thermal injury. While unilateral injury is more frequent, bilateral injury is a dreaded complication that often results in the vocal cords assuming a median or paramedian position, leading to acute airway obstruction and necessitating an emergency tracheostomy. **2. Analysis of Incorrect Options:** * **Bronchogenic Carcinoma:** This is the most common cause of **unilateral** left-sided RLN palsy. The left RLN loops around the arch of the aorta and is susceptible to compression by mediastinal lymph nodes or apical lung tumors (Pancoast tumor). It rarely presents bilaterally. * **Carcinoma of the Esophagus:** While esophageal malignancies can involve the RLN (more commonly the left), they typically present with unilateral involvement and are less common causes than surgical trauma. * **Neck Trauma:** Penetrating or blunt neck trauma can injure the RLN, but such injuries are usually focal and unilateral. **Clinical Pearls for NEET-PG:** * **Most common cause of Unilateral RLN palsy:** Malignancy (specifically Bronchogenic Carcinoma). * **Most common cause of Bilateral RLN palsy:** Surgical trauma (Thyroidectomy). * **Position of cords:** In bilateral complete palsy, cords lie in the **median/paramedian** position (adducted), causing inspiratory stridor but a relatively preserved voice. * **Semon’s Law:** States that in progressive lesions of the RLN, the abductor fibers (posterior cricoarytenoid) are injured before the adductor fibers.

Q: A chronic smoker with a history of hoarseness of voice is found to have fixation of the vocal cords on examination. What is the most likely treatment he will require?

Subtotal laryngectomy. **Explanation:** The clinical presentation of a chronic smoker with hoarseness and **fixation of the vocal cords** is a hallmark sign of **Stage T3 Glottic Carcinoma**. In laryngeal cancer, vocal cord fixation indicates that the tumor has invaded deep structures such as the thyroarytenoid muscle, the cricoarytenoid joint, or the paraglottic space. 1. **Why Subtotal Laryngectomy is correct:** For T3 lesions (fixed cord), the standard of care involves aggressive management. While total laryngectomy was traditionally the gold standard, **Subtotal Laryngectomy** (specifically Supracricoid Laryngectomy) is an organ-preserving surgical option that allows for the removal of the tumor while maintaining physiological speech and swallowing without a permanent stoma. 2. **Why other options are incorrect:** * **Stripping of the vocal cord:** This is used for benign lesions (like Reinke’s edema) or Carcinoma-in-situ (Tis). It is inadequate for invasive cancer with cord fixation. * **Radiotherapy:** While RT can be used for T3 lesions in some protocols, surgery (Subtotal or Total Laryngectomy) is often preferred for advanced local disease with cord fixation to ensure clear margins, especially if the patient is a heavy smoker with a high risk of recurrence. * **Laser cordectomy:** This is indicated for early-stage lesions (T1a) where the cord is still mobile. It cannot address deep infiltration causing fixation. **Clinical Pearls for NEET-PG:** * **T1:** Tumor limited to vocal cord(s); normal mobility. * **T2:** Tumor extends to supraglottis/subglottis; **impaired** mobility. * **T3:** Tumor limited to larynx with **vocal cord fixation**. * **T4:** Invasion through thyroid cartilage or into extrinsic tissues. * **Most common site** of laryngeal cancer: Glottis. * **Most common pathology:** Squamous Cell Carcinoma.

Q: What is the T stage for carcinoma of the epiglottis involving the pre-epiglottic space?

T3 stage. **Explanation:** The staging of Supraglottic Laryngeal Carcinoma (which includes the epiglottis) is determined by the extent of local invasion and vocal cord mobility. **Why T3 is the correct answer:** According to the AJCC (8th Edition) TNM staging for the supraglottis, a tumor is classified as **T3** if it is limited to the larynx but involves any of the following: 1. **Invasion of the pre-epiglottic space.** 2. Invasion of the paraglottic space. 3. Fixation of the vocal cords. 4. Inner cortex of the thyroid cartilage invasion. The pre-epiglottic space is a fat-filled potential space located anterior to the epiglottis; its involvement signifies deeper infiltration, upgrading the stage to T3. **Why other options are incorrect:** * **T1:** The tumor is limited to one subsite of the supraglottis (e.g., lingual surface of the epiglottis) with normal vocal cord mobility. * **T2:** The tumor invades more than one adjacent subsite of the supraglottis or glottis, or a region outside the supraglottis (e.g., mucosa of the base of tongue), without fixation of the larynx. * **T4:** This represents advanced disease. **T4a** involves invasion through the outer cortex of the thyroid cartilage or into soft tissues of the neck (thyroid, esophagus). **T4b** involves the prevertebral space or encasement of the carotid artery. **High-Yield Clinical Pearls for NEET-PG:** * **Pre-epiglottic space:** Bound by the hyoid bone (superiorly), thyroid cartilage/thyrohyoid membrane (anteriorly), and epiglottis (posteriorly). * **Hyo-epiglottic ligament:** Forms the "roof" of the pre-epiglottic space. * **Most common site** of Supraglottic CA: Epiglottis. * **Lymphatic spread:** Supraglottic tumors have a rich lymphatic network; hence, bilateral neck node involvement is common compared to glottic tumors.

Q: Which of the following procedures is NOT done in bilateral abductor palsy of vocal cords?

Teflon paste injection. **Explanation:** In **Bilateral Abductor Palsy**, the vocal cords are paralyzed in the midline or paramedian position. This results in a compromised airway (stridor) but a relatively preserved voice. The primary goal of management is to **widen the glottic chink** to improve breathing. **Why Teflon Paste Injection is the Correct Answer:** Teflon paste injection is a **medialization procedure**. It is used to add bulk to a vocal cord that is paralyzed in the lateral position (Unilateral Vocal Cord Palsy) to improve glottic closure and voice quality. In bilateral abductor palsy, the cords are already at the midline; injecting Teflon would further narrow the airway, potentially causing total obstruction. Therefore, it is contraindicated. **Analysis of Other Options:** * **Cordectomy:** Involves the surgical removal of a portion of the vocal cord (usually the posterior part) to create a larger airway space. * **Arytenoidectomy:** Removal of the arytenoid cartilage (e.g., Woodman’s procedure) to widen the posterior glottis. This is a classic surgical treatment for bilateral abductor palsy. * **Nerve Muscle Implant:** A reinnervation technique (e.g., using the omohyoid muscle and ansa cervicalis) aimed at restoring the function of the posterior cricoarytenoid muscle (the only abductor). **Clinical Pearls for NEET-PG:** * **Most common cause** of bilateral abductor palsy: Thyroid surgery (injury to bilateral Recurrent Laryngeal Nerves). * **Treatment Priority:** Airway first (Tracheostomy if acute), followed by permanent widening procedures (Lateralization). * **Trade-off:** Any procedure that improves the airway in these patients (by lateralizing the cords) will inevitably worsen the quality of the voice.

Question 1

All of the following conditions affect the posterior part of the larynx except?

Accepted Answer

Lupus

Answer

Contact ulcer

Answer

Pachydermia laryngis

Answer

Intubation granuloma

Question 2

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)

Question 3

Which of the following could be an indication for performing a high tracheostomy in a middle-aged man?

Accepted Answer

Carcinoma

Answer

Tuberculosis

Answer

Tetanus

Answer

Diphtheria

Question 4

What is the treatment of choice for recurrent respiratory papillomatosis?

Accepted Answer

Laser ablation

Answer

Diathermy excision

Answer

Excision with microdebrider

Answer

Wait for spontaneous resolution

Question 5

A patient with which of the following is a candidate for a supraglottic laryngectomy?

Accepted Answer

A lesion of the laryngeal surface of the epiglottis below the hyoid bone with evidence of preepiglottic space invasion on computed tomography

Answer

A T2 lesion of the right aryepiglottic fold, a right false vocal cord, and impaired mobility of the true vocal cord

Answer

A lesion of the epiglottis, vallecula, and 1-cm, unilateral extension to the tongue base

Answer

An invasive lesion of the false vocal cord that is found to extend significantly into the ventricle at the time of surgical endoscopy

Question 6

Reinke's edema is typically seen in which part of the larynx?

Accepted Answer

Edges of vocal cords

Answer

Vestibular folds

Answer

Between true and false vocal cords

Answer

Pyriform fossa

Question 7

Bilateral recurrent laryngeal nerve palsy is most commonly associated with which of the following conditions?

Accepted Answer

Thyroid surgery

Answer

Neck trauma

Answer

Bronchogenic carcinoma

Answer

Carcinoma of the esophagus

Question 8

A chronic smoker with a history of hoarseness of voice is found to have fixation of the vocal cords on examination. What is the most likely treatment he will require?

Accepted Answer

Subtotal laryngectomy

Answer

Stripping of the vocal cord

Answer

Radiotherapy

Answer

Laser cordectomy

Question 9

What is the T stage for carcinoma of the epiglottis involving the pre-epiglottic space?

Accepted Answer

T3 stage

Answer

T2 stage

Answer

T1 stage

Answer

T4 stage

Question 10

Which of the following procedures is NOT done in bilateral abductor palsy of vocal cords?

Accepted Answer

Teflon paste injection

Answer

Cordectomy

Answer

Nerve muscle implant

Answer

Arytenoidectomy

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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