Diseases of the Larynx Practice Questions

Q: Treatment for unilateral vocal cord palsy includes which of the following procedures?

Isshiki type I thyroplasty. **Explanation:** The primary goal in treating **unilateral vocal cord palsy** is to improve voice quality by moving the paralyzed cord to the midline so the healthy cord can make contact (medialization). **Why Option A is Correct:** **Isshiki Type I Thyroplasty** is a **medialization laryngoplasty**. It involves creating a window in the thyroid cartilage and placing an implant (e.g., Silastic or Gore-Tex) to push the paralyzed vocal cord toward the midline. This allows for better glottic closure during phonation, effectively treating the breathy dysphonia associated with unilateral palsy. **Why Other Options are Incorrect:** * **Isshiki Type II Thyroplasty:** This is a **lateralization** procedure used for Spasmodic Dysphonia (Adductor type) to move the cords apart and reduce voice strain. * **Woodman Operation & Laser Arytenoidectomy (Options C & D):** These are **lateralization procedures** used to treat **bilateral abductor palsy**. In bilateral palsy, the airway is compromised because the cords are stuck in the midline; therefore, the goal is to move them apart to improve breathing, which is the opposite of what is needed for unilateral palsy. **High-Yield Clinical Pearls for NEET-PG:** * **Isshiki Classification of Thyroplasty:** * **Type I:** Medialization (for Unilateral Palsy). * **Type II:** Lateralization (for Spasmodic Dysphonia). * **Type III:** Relaxation/Shortening (to lower pitch). * **Type IV:** Stretching/Tension (to raise pitch, e.g., in Androphonia/Puberphonia). * **Wait and Watch:** For unilateral palsy, definitive surgery is usually delayed for **6–12 months** to allow for spontaneous recovery, unless the cause is known to be permanent (e.g., nerve transection). * **Gelfoam Injection:** A temporary medialization technique used if recovery is expected.

Q: A 30-year-old female with a history of singing, vocal abuse, and gastroesophageal reflux developed nodules at the junction of the anterior one-third and middle one-third of her vocal cords. What is the treatment of choice?

Speech therapy and Proton pump inhibitor (PPI). **Explanation:** The clinical presentation describes **Vocal Nodules** (also known as Singer’s or Screamer’s nodules). These are benign, inflammatory callous-like thickenings that typically occur bilaterally at the **junction of the anterior 1/3 and posterior 2/3** (the mid-point of the membranous cord), which is the area of maximum vibratory amplitude. **Why Option A is Correct:** The primary etiology of vocal nodules is chronic vocal abuse/misuse. In this patient, the history of singing and vocal abuse, compounded by GERD (which causes laryngeal irritation), confirms the diagnosis. The **first-line treatment** for vocal nodules is always conservative: 1. **Speech/Voice Therapy:** To correct faulty vocal habits and reduce trauma to the cords. 2. **Medical Management:** Treating aggravating factors like GERD with PPIs. Most nodules, especially early/soft ones, regress with these measures. **Why Other Options are Incorrect:** * **Options B & C (Surgical intervention):** Microlaryngoscopic surgery (MLS) or CO2 laser excision is reserved only for large, chronic, or "fibrotic" nodules that fail to respond to a minimum of 3–6 months of conservative therapy. Surgery without voice therapy often leads to recurrence. * **Option D (Biopsy):** Vocal nodules have a characteristic appearance and history; a biopsy is generally unnecessary unless there is a suspicion of malignancy (which is rare in a young, non-smoking female with bilateral lesions). **High-Yield Clinical Pearls for NEET-PG:** * **Site:** Junction of anterior 1/3 and posterior 2/3 (membranous part). * **Nature:** Usually bilateral and symmetrical. * **Histology:** Early nodules are edematous; late nodules are fibrotic/hyalinized. * **Vocal Polyps vs. Nodules:** Polyps are usually unilateral, often follow a single episode of vocal trauma, and more frequently require surgical excision compared to nodules.

Q: Laryngocele arises from which anatomical structure?

Saccule of the ventricle. **Explanation:** **Laryngocele** is an abnormal cystic dilatation of the **saccule of the laryngeal ventricle**. The saccule (or appendix of the ventricle) is a blind pouch containing mucous glands, located between the false vocal cords and the inner aspect of the thyroid cartilage. When the neck of this saccule becomes obstructed (due to inflammation or tumors) or subjected to increased intralaryngeal pressure (e.g., in trumpet players or glassblowers), it distends with air, forming a laryngocele. **Analysis of Options:** * **Option B (Correct):** The saccule is the anatomical origin. If it contains air, it is a laryngocele; if it fills with mucus, it is a **laryngopyocele**. * **Option A (Anterior commissure):** This is the junction where the two vocal cords meet anteriorly. It is a critical landmark for tumor spread (Broyle’s ligament) but not the site of origin for laryngoceles. * **Options C & D (True and False Vocal Cords):** While the ventricle lies *between* the true and false cords, the laryngocele specifically arises from the saccule extending superiorly from the ventricle, not the cords themselves. **High-Yield Clinical Pearls for NEET-PG:** 1. **Types:** * **Internal:** Confined to the larynx (presents with hoarseness/stridor). * **External:** Pierces the **thyrohyoid membrane** (presents as a neck mass that expands with the Valsalva maneuver). * **Combined:** Features of both. 2. **Bryce’s Sign:** Gurgling sound heard on compression of the external swelling. 3. **Radiology:** CT scan is the gold standard, showing an air-filled sac. 4. **Association:** In adults, always rule out **Squamous Cell Carcinoma** of the ventricle obstructing the saccule orifice.

Q: Which investigation is used for the diagnosis of laryngopharyngeal reflux?

Dual probe impedance pH monitoring. **Explanation:** **Laryngopharyngeal Reflux (LPR)**, often called "silent reflux," occurs when gastric contents reach the larynx and pharynx. Unlike GERD, LPR involves the retrograde flow of both acidic and non-acidic (pepsin, bile) material into the upper aerodigestive tract. 1. **Why Option B is Correct:** **Dual probe multichannel intraluminal impedance (MII) pH monitoring** is the **Gold Standard** for diagnosing LPR. * **Dual Probe:** One sensor is placed in the distal esophagus (to detect GERD) and the second is placed in the hypopharynx (to detect LPR). * **Impedance:** Unlike traditional pH probes that only detect acid (pH < 4), impedance can detect **non-acidic and gaseous reflux**, which is common in LPR patients who often do not respond to standard PPI therapy. 2. **Why other options are incorrect:** * **A. Esophageal pH monitoring:** This uses a single probe in the distal esophagus. While excellent for GERD, it cannot confirm if the refluxate has reached the laryngeal level. * **C. Barium esophagram:** This is a structural study used to identify anatomical abnormalities (strictures, webs, or hiatal hernias) but has very low sensitivity for detecting intermittent reflux episodes. * **D. Scintigraphy:** This involves swallowing radioactive isotopes. While it can detect aspiration, it is not a standard diagnostic tool for LPR due to poor sensitivity and lack of standardized protocols. **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 and pseudosulcus vocalis. * **Reflux Finding Score (RFS):** A clinical tool used during laryngoscopy to quantify the severity of LPR. * **Treatment:** LPR requires more aggressive treatment than GERD, often requiring twice-daily (BID) PPIs for 3–6 months.

Q: Which is the narrowest part of the larynx in children?

Subglottic. **Explanation:** The larynx undergoes significant anatomical changes during development. In children (infants and young children), the **Subglottic region** (specifically at the level of the **Cricoid cartilage**) is the narrowest part of the airway. **1. Why Subglottic is Correct:** In pediatric anatomy, the larynx is shaped like a **funnel** or a cone. The cricoid cartilage is the only complete cartilaginous ring in the respiratory tract. Because it is a rigid, non-expandable circle, any mucosal edema in this region significantly compromises the airway. This is the physiological basis for why **Croup (Laryngotracheobronchitis)** is so dangerous in children. **2. Why other options are incorrect:** * **Glottic region (Option C):** In **adults**, the glottis (the space between the vocal cords) is the narrowest part. As a child matures, the larynx transitions from a funnel shape to a **cylindrical** shape, shifting the narrowest point upward to the glottis. * **Supraglottic (Option A):** This area is wider and more distensible; while it can be affected by infections (like Epiglottitis), it is not the narrowest anatomical point. **Clinical Pearls for NEET-PG:** * **Shape:** Pediatric larynx is **funnel-shaped**; Adult larynx is **cylindrical**. * **Position:** The pediatric larynx is higher in the neck (at the level of **C3-C4**) compared to adults (**C4-C6**). * **Poiseuille’s Law:** Because the subglottis is the narrowest point, 1 mm of edema reduces the cross-sectional area by approximately 75% in an infant, compared to only 44% in an adult. * **Uncuffed Tubes:** Historically, uncuffed endotracheal tubes were preferred in children to prevent pressure necrosis at the narrow cricoid level (though modern practice is evolving).

Q: Which part of the larynx shows the highest lymph node involvement in carcinoma?

Supraglottic carcinoma. ### Explanation The correct answer is **Supraglottic carcinoma**. The incidence of lymph node metastasis in laryngeal cancer is directly proportional to the density of the lymphatic capillary network in that specific anatomical site. **1. Why Supraglottic Carcinoma is Correct:** The supraglottis (epiglottis, aryepiglottic folds, false cords) possesses an **extremely rich and dense network of lymphatic vessels**. These vessels pierce the thyrohyoid membrane to drain into the deep cervical (Level II, III, and IV) nodes. Approximately **40–50%** of patients with supraglottic SCC present with clinically palpable nodes at the time of diagnosis, and bilateral spread is common due to the midline nature of structures like the epiglottis. **2. Why Other Options are Incorrect:** * **Glottic Carcinoma:** The vocal cords (glottis) have **virtually no lymphatic drainage** (Reinke’s space acts as a barrier). Consequently, lymph node metastasis is extremely rare (<1%) in early glottic cancer. This is why glottic cancers have the best prognosis. * **Subglottic Carcinoma:** While the subglottis has a moderate lymphatic supply (draining to paratracheal and prelaryngeal/Delphian nodes), it is a rare site for primary tumors. The incidence of nodal involvement (approx. 20%) is significantly lower than in supraglottic lesions. * **Equal Incidence:** This is incorrect because of the stark anatomical differences in lymphatic density described above. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of laryngeal cancer:** Glottis (but lowest nodal spread). * **Best prognosis:** Glottic cancer (due to early symptoms like hoarseness and poor lymphatics). * **Worst prognosis:** Subglottic cancer (often diagnosed late and spreads to paratracheal nodes). * **Delphian Node:** The prelaryngeal node; its involvement often suggests subglottic or thyroid extension. * **Most common histology:** Squamous Cell Carcinoma (SCC) (>95%).

Q: What is true about Ackermans tumor?

It is verrucous carcinoma of the larynx. **Explanation:** **Ackerman’s Tumor**, also known as **Verrucous Carcinoma**, is a specific, well-differentiated variant of squamous cell carcinoma. It typically presents as a slow-growing, exophytic, "wart-like" or cauliflower-like mass, most commonly involving the vocal cords. * **Why Option B is correct:** Ackerman’s tumor is the eponymous name for verrucous carcinoma. It is characterized histologically by a "pushing" rather than an "infiltrating" margin, with minimal cellular atypia. * **Why Option A is incorrect:** Despite its bulky appearance, it is a **low-grade**, locally aggressive tumor with a very low potential for distant metastasis. It is considered "clinically malignant but histologically benign-looking." * **Why Option C is incorrect:** **Surgery** (wide local excision) is the treatment of choice. Radiotherapy is generally avoided because it is relatively radioresistant and carries a risk of inducing **anaplastic transformation** into a highly aggressive spindle cell carcinoma. * **Why Option D is incorrect:** A hallmark of Ackerman’s tumor is that it **rarely spreads to regional lymph nodes**. Lymphadenopathy, if present, is usually reactive/inflammatory rather than metastatic. **High-Yield Clinical Pearls for NEET-PG:** * **Appearance:** "Chewing gum" or "Cauliflower" appearance. * **Common Site:** Glottis (Larynx) and Oral Cavity (associated with tobacco chewing). * **Histology:** Characterized by "church-spire" keratosis and a "pushing" border. * **Prognosis:** Excellent if surgically excised, as it does not metastasize.

Q: Respiratory compromise is typically seen in which condition?

Bilateral recurrent laryngeal nerve palsy. **Explanation:** The primary function of the **Recurrent Laryngeal Nerve (RLN)** is to supply all intrinsic muscles of the larynx except the cricothyroid. Crucially, it supplies the **posterior cricoarytenoid (PCA)**, which is the sole abductor of the vocal cords. **1. Why Option A is Correct:** In **Bilateral Recurrent Laryngeal Nerve Palsy**, both vocal cords lose their ability to abduct. According to **Semon’s Law**, the abductor fibers are more vulnerable than adductor fibers. Consequently, the cords assume a **median or paramedian position**. This significantly narrows the glottic chink, leading to acute **respiratory compromise** and inspiratory stridor, often necessitating an emergency tracheostomy. **2. Why the Incorrect Options are Wrong:** * **Option B:** In combined palsy (Superior + Recurrent), the cricothyroid (tenser) is also paralyzed. This results in a "cadaveric" position (mid-way between midline and lateral). While the voice is very breathy, the airway remains adequate. * **Option C & D:** In **Unilateral RLN Palsy** (complete or incomplete), the unaffected vocal cord can usually compensate by crossing the midline to meet the paralyzed cord. While this causes hoarseness of voice, the airway remains patent, and there is no respiratory distress. **High-Yield Clinical Pearls for NEET-PG:** * **Semon’s Law:** In progressive lesions of the RLN, abductor fibers are damaged before adductor fibers. * **Wagner and Grossman Theory:** The cricothyroid muscle (supplied by the Superior Laryngeal Nerve) keeps the cord in a paramedian position even if the RLN is out. * **Most common cause of Bilateral RLN Palsy:** Thyroid surgery (total thyroidectomy). * **Management:** Emergency tracheostomy for airway; later, lateralization of the cord (e.g., Woodman’s operation).

Q: Topical mitomycin-C is used in which of the following conditions?

Laryngotracheal stenosis. **Explanation:** **Laryngotracheal Stenosis (Correct Answer):** Mitomycin-C (MMC) is a potent fibroblast inhibitor derived from *Streptomyces caespitosus*. In ENT, it is used topically (typically 0.4 mg/ml) to prevent the formation of excessive scar tissue. In **Laryngotracheal Stenosis (LTS)** and subglottic stenosis, it is applied following endoscopic dilation or laser excision. By inhibiting DNA synthesis and fibroblast proliferation, it reduces the deposition of collagen, thereby preventing restenosis and improving the long-term patency of the airway. **Analysis of Incorrect Options:** * **Sturge-Weber Syndrome:** This is a neurocutaneous disorder characterized by port-wine stains and leptomeningeal angiomas. Management involves laser therapy for skin lesions and anticonvulsants; MMC has no role here. * **Endoscopic Angiofibroma:** Juvenile Nasopharyngeal Angiofibroma (JNA) is a highly vascular tumor. The mainstay of treatment is preoperative embolization followed by surgical excision. MMC does not address the vascular nature of this tumor. * **Skull Base Osteomyelitis:** This is a severe infection (usually Pseudomonas) requiring long-term intravenous antibiotics and surgical debridement. MMC, an antiproliferative agent, is contraindicated in active infections as it may impair healing. **High-Yield Clinical Pearls for NEET-PG:** * **Other ENT uses of Mitomycin-C:** Prevention of synechiae after Functional Endoscopic Sinus Surgery (FESS), maintaining patency of choanal atresia repair, and preventing closure of a myringotomy (prolonging tube patency). * **Mechanism:** It acts as an alkylating agent that cross-links DNA. * **Application:** It is applied topically via a soaked cottonoid for approximately 2–5 minutes. * **LTS Grading:** Remember the **Cotton-Myer Classification** for grading the severity of subglottic stenosis based on the percentage of lumen reduction.

Question 1

Treatment for unilateral vocal cord palsy includes which of the following procedures?

Accepted Answer

Isshiki type I thyroplasty

Answer

Isshiki type II thyroplasty

Answer

Woodman operation

Answer

Laser arytenoidectomy

Question 2

A 30-year-old female with a history of singing, vocal abuse, and gastroesophageal reflux developed nodules at the junction of the anterior one-third and middle one-third of her vocal cords. What is the treatment of choice?

Accepted Answer

Speech therapy and Proton pump inhibitor (PPI)

Answer

Microlaryngoscopic surgery and CO2 laser

Answer

Microlaryngectomy

Answer

Direct laryngoscopy and biopsy

Question 3

Laryngocele arises from which anatomical structure?

Accepted Answer

Saccule of the ventricle

Answer

Anterior commissure

Answer

True vocal cords

Answer

False vocal cords

Question 4

Which investigation is used for the diagnosis of laryngopharyngeal reflux?

Accepted Answer

Dual probe impedance pH monitoring

Answer

Esophageal pH monitoring

Answer

Barium esophagram

Answer

Scintigraphy

Question 5

Which is the narrowest part of the larynx in children?

Accepted Answer

Subglottic

Answer

Supraglottic

Answer

Glottic region

Answer

None

Question 6

Which part of the larynx shows the highest lymph node involvement in carcinoma?

Accepted Answer

Supraglottic carcinoma

Answer

Glottic carcinoma

Answer

Subglottic carcinoma

Answer

Equal incidence in all locations

Question 7

What is true about Ackermans tumor?

Accepted Answer

It is verrucous carcinoma of the larynx

Answer

It is a highly malignant tumor

Answer

Radiotherapy is the treatment of choice

Answer

It spreads via lymphatics in the early stage

Question 8

Respiratory compromise is typically seen in which condition?

Accepted Answer

Bilateral recurrent laryngeal nerve palsy

Answer

Superior and recurrent laryngeal nerve palsy

Answer

Incomplete unilateral recurrent laryngeal nerve palsy

Answer

Complete unilateral recurrent laryngeal nerve palsy

Question 9

Topical mitomycin-C is used in which of the following conditions?

Accepted Answer

Laryngotracheal stenosis

Answer

Sturge-Weber syndrome

Answer

Endoscopic angiofibroma

Answer

Skull base osteomyelitis

Question 10

In tracheostomy, the entry into the trachea is through which anatomical structures?

Accepted Answer

Second and third tracheal rings

Answer

Cricoid cartilage

Answer

First tracheal ring

Answer

Fourth and fifth tracheal rings

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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