Voice Disorders — MCQs
To distinguish between cochlear and post-cochlear damage, which test is done?
A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
Which of the following changes in voice is not produced as a result of external laryngeal nerve injury post thyroidectomy?
A 45-year-old patient presents with persistent hoarseness for 3 months. Which finding on indirect laryngoscopy is most concerning for malignancy?
The voice in a patient with bilateral abductor paralysis of the larynx is most likely to be?
Hot potato voice is characteristic of ?
A 16-year-old patient complains of difficulty in swallowing, difficulty in talking and sometimes difficulty in breathing. On physical examination the presentation is similar to that shown in the picture. What would be the probable diagnosis?
The following image shows:
The image shows which of the following tests being performed? (Recent NEET Pattern 2016-17)
Which part of the larynx is most commonly involved in tuberculosis (TB)?
Voice Disorders Indian Medical PG Practice Questions and MCQs
Question 1: To distinguish between cochlear and post-cochlear damage, which test is done?
- A. Auditory brainstem response (ABR) (Correct Answer)
- B. Impedance audiometry
- C. Pure tone audiometry
- D. Electrocochleography (ECochG)
Explanation: ***Auditory brainstem response (ABR)*** - This test evaluates the integrity of the **auditory pathway from the cochlea through the brainstem**, making it excellent for differentiating between cochlear (sensory) and post-cochlear (retrocochlear/neural) lesions. - Abnormalities in wave latencies or interpeak intervals suggest **retrocochlear pathology** (e.g., acoustic neuroma), while normal ABR responses despite hearing loss point towards cochlear damage. - ABR records **five characteristic waves (I-V)** representing neural transmission from the auditory nerve through the brainstem. *Impedance audiometry* - Primarily assesses the **middle ear function**, including the eardrum and ossicles, by measuring **tympanic membrane compliance** and **acoustic reflexes**. - It does not directly evaluate the function of the **cochlea or the retrocochlear pathways**, making it unsuitable for this differentiation. *Pure tone audiometry* - Measures a person's **hearing sensitivity** at different frequencies and provides information on the **degree and type of hearing loss (conductive, sensorineural, or mixed)**. - While it identifies sensorineural hearing loss, it cannot pinpoint whether the damage is **cochlear or retrocochlear** within the sensorineural category. *Electrocochleography (ECochG)* - Records **electrical potentials generated by the cochlea and auditory nerve** in response to sound, including **cochlear microphonics, summating potentials, and compound action potentials**. - While it evaluates cochlear function and is useful in diagnosing **Meniere's disease** and **auditory neuropathy**, it does not adequately assess the **integrity of the brainstem auditory pathways** needed to differentiate retrocochlear lesions.
Question 2: A man takes peanut and develops tongue swelling, neck swelling, stridor, hoarseness of voice. What is the probable diagnosis?
- A. FB in larynx
- B. Angioneurotic edema (Correct Answer)
- C. Parapharyngeal abscess
- D. FB bronchus
Explanation: Andioneurotic edema - The combination of **tongue swelling**, **neck swelling**, **stridor**, and **hoarseness of voice** following peanut ingestion is highly suggestive of **angioneurotic edema**, a severe allergic reaction that can lead to airway obstruction [1]. - This is a life-threatening condition requiring immediate medical intervention, often associated with generalized **anaphylaxis** when triggered by allergens [2]. *FB in larynx* - While a **foreign body (FB) in the larynx** can cause stridor and hoarseness, the widespread swelling of the tongue and neck points away from a localized laryngeal obstruction [3]. - A laryngeal FB would typically be associated with a more sudden onset of choking and coughing, not diffuse edema [3]. *Parapharyngeal abscess* - A **parapharyngeal abscess** would typically present with **fever**, **severe throat pain**, and **trismus** (difficulty opening the mouth), which are not mentioned in this scenario. - The acute, rapid onset of symptoms after peanut consumption is inconsistent with the slower progression of an abscess. *FB bronchus* - A **foreign body in the bronchus** would primarily cause **coughing**, **wheezing**, and possibly **respiratory distress**, often unilateral, rather than severe global swelling of the tongue and neck. - Inspiratory stridor and hoarseness are more indicative of upper airway involvement than bronchial obstruction.
Question 3: Which of the following changes in voice is not produced as a result of external laryngeal nerve injury post thyroidectomy?
- A. Inability to sing at higher ranges
- B. Poor volume and projection
- C. Hoarseness (Correct Answer)
- D. Voice fatigue
Explanation: ***Hoarseness*** - **Hoarseness** is primarily caused by injury to the **recurrent laryngeal nerve (RLN)**, which innervates most intrinsic laryngeal muscles responsible for vocal cord adduction and abduction. - An external laryngeal nerve (ELN) injury affects the **cricothyroid muscle**, leading to less tension on the vocal cords, but typically not frank hoarseness. *Voice fatigue* - Injury to the external laryngeal nerve (ELN) weakens the **cricothyroid muscle**, which is responsible for tensing and elongating the vocal cords. - This weakness leads to greater effort required to maintain vocal quality, resulting in **voice fatigue**. *Inability to sing at higher ranges* - The **cricothyroid muscle**, innervated by the ELN, is crucial for increasing vocal cord tension. - Increased tension is necessary for adjusting vocal pitch and reaching **higher frequencies** or notes. *Poor volume and projection* - The cricothyroid muscle's role in vocal cord tension contributes to the efficiency of vocal fold vibration. - Reduced tension due to ELN injury can lead to decreased **vocal power and projection**.
Question 4: A 45-year-old patient presents with persistent hoarseness for 3 months. Which finding on indirect laryngoscopy is most concerning for malignancy?
- A. Reinke's edema
- B. Unilateral cord paralysis (Correct Answer)
- C. Bilateral polyps
- D. Vocal cord nodules
Explanation: ***Unilateral cord paralysis*** - **Unilateral cord paralysis** can be an indicator of an underlying malignancy impinging on the **recurrent laryngeal nerve**, which innervates the vocal cords. - The **persistent hoarseness** for 3 months, combined with paralysis, raises significant concern for a malignant process in the head, neck, or chest. *Reinke's edema* - **Reinke's edema** is typically associated with **chronic irritation** like smoking and presents as a swollen, gelatinous fluid collection in the superficial lamina propria. - While it causes hoarseness, it is a **benign condition** and not directly indicative of malignancy. *Bilateral polyps* - **Vocal cord polyps** are typically **benign lesions** often caused by vocal trauma or abuse, and while they can cause hoarseness, they are not usually a direct sign of malignancy, especially when bilateral. - While requiring management, polyps themselves do **not raise immediate concern for cancer** compared to paralysis. *Vocal cord nodules* - **Vocal cord nodules** (singer's nodules) are benign, bilateral lesions caused by **vocal abuse** and are a common cause of hoarseness. - They are a benign condition and do not suggest an underlying malignancy at their core.
Question 5: The voice in a patient with bilateral abductor paralysis of the larynx is most likely to be?
- A. Weak or breathy voice
- B. Normal voice (Correct Answer)
- C. Voice fatigue
- D. Strained voice
Explanation: ***Normal voice*** - In **bilateral abductor paralysis**, both posterior cricoarytenoid muscles (the only intrinsic laryngeal muscles that abduct the vocal cords) are paralyzed - The vocal cords remain fixed in a **paramedian position** (nearly closed but not completely closed) - This position is **ideal for phonation** as the vocal cords are adequately approximated for normal voice production - Therefore, voice quality remains **normal or near-normal** despite the paralysis - The **primary clinical problem** is severe **inspiratory stridor and respiratory distress** due to narrowed airway, not voice quality - This is a **life-threatening emergency** requiring urgent airway management *Weak or breathy voice* - A **breathy voice** occurs when vocal cords cannot adequately **adduct** (close), allowing air to escape during phonation - This is characteristic of **adductor paralysis** (recurrent laryngeal nerve injury causing vocal cord paralysis in abducted position) or **unilateral vocal cord paralysis** - In bilateral abductor paralysis, the cords are already in near-midline position, so phonation is preserved *Strained voice* - A **strained or pressed voice** is associated with **muscle tension dysphonia**, **paradoxical vocal fold motion**, or **hyperkinetic voice disorders** - It occurs when excessive laryngeal tension is present during phonation - This is **not** characteristic of bilateral abductor paralysis where the cords are passively positioned near midline *Voice fatigue* - **Voice fatigue** is a symptom of prolonged voice use or underlying pathologies like **vocal nodules**, **polyps**, or **muscle tension dysphonia** - It describes deterioration of voice quality with use, not a baseline voice characteristic - Not a primary feature of bilateral abductor paralysis
Question 6: Hot potato voice is characteristic of ?
- A. Nasopharyngeal carcinoma
- B. Glottic carcinoma
- C. Subglottic carcinoma
- D. Supraglottic carcinoma (Correct Answer)
Explanation: ***Supraglottic carcinoma*** - Among the given options, **supraglottic carcinoma** is the best answer, as it can produce a **"hot potato" voice** (also known as a "muffled" or "potato-in-the-mouth" voice) due to tumor bulk in the supraglottic region. - The tumor interferes with normal resonance and articulation of speech by reducing the pharyngeal space and impairing the mobility of the **epiglottis** and aryepiglottic folds. - **Clinical note:** Hot potato voice is **classically** associated with **acute supraglottic inflammatory conditions** such as **peritonsillar abscess (quinsy)**, **acute epiglottitis**, and **retropharyngeal abscess** rather than malignancies. However, any mass lesion in the supraglottic region that causes pharyngeal space reduction can theoretically produce this voice quality. *Nasopharyngeal carcinoma* - **Nasopharyngeal carcinoma** is located in the **nasopharynx** (above the soft palate) and typically presents with **nasal obstruction**, epistaxis, **conductive hearing loss** (Eustachian tube involvement), and cranial nerve palsies. - It does not affect the supraglottic larynx or oropharynx in a way that would produce the characteristic "hot potato" voice. *Glottic carcinoma* - **Glottic carcinoma** primarily affects the **true vocal cords**, leading to early symptoms of **progressive hoarseness** or dysphonia due to impaired vocal cord vibration. - While it affects voice quality significantly, it produces a **hoarse or breathy voice**, not the muffled "hot potato" quality associated with supraglottic space-occupying lesions. *Subglottic carcinoma* - **Subglottic carcinoma** is located **below the true vocal cords** and is the rarest laryngeal malignancy, often presenting late with **stridor** and **dyspnea** due to airway narrowing. - Voice changes occur late and are related to **airway obstruction** or superior extension to the vocal cords, not the characteristic muffled sound of a "hot potato" voice.
Question 7: A 16-year-old patient complains of difficulty in swallowing, difficulty in talking and sometimes difficulty in breathing. On physical examination the presentation is similar to that shown in the picture. What would be the probable diagnosis?
- A. Ranula
- B. Lingual thyroid (Correct Answer)
- C. Enlarged adenoids
- D. Vallecular cyst
Explanation: ***Lingual thyroid*** - The image shows a **mass at the base of the tongue**, which is typical of a lingual thyroid, an ectopic thyroid tissue. - Symptoms like **difficulty swallowing (dysphagia)**, **difficulty talking (dysphonia)**, and **difficulty breathing (dyspnea)** are common with a lingual thyroid due to its obstructive nature. - Lingual thyroid results from **failure of thyroid descent** during embryological development and is the most common ectopic thyroid location. *Ranula* - A ranula is a **mucus extravasation cyst** found on the **floor of the mouth**, usually unilateral and bluish. - While it can cause speech or swallowing difficulties, its location is distinct from the mass seen at the tongue base. *Vallecular cyst* - A vallecular cyst is a **mucus retention cyst** located in the **vallecula** (between the base of tongue and epiglottis). - Can present with dysphagia and respiratory symptoms, but typically appears more **cystic and translucent** rather than solid tissue mass. - Less common in adolescents compared to lingual thyroid. *Enlarged adenoids* - Enlarged adenoids are located in the **nasopharynx** and typically cause nasal obstruction, mouth breathing, and recurrent ear infections. - They would not present as a visible mass at the base of the tongue nor cause dysphagia or dysphonia to this extent.
Question 8: The following image shows:
- A. Respiratory papillomatosis (Correct Answer)
- B. Vocal nodule
- C. Vocal polyp
- D. TB of vocal cords
Explanation: ***Respiratory papillomatosis*** - The image displays multiple **wart-like growths** on the vocal cords, characteristic of **respiratory papillomatosis**, which is caused by the **human papillomavirus (HPV)**. - These lesions often have an **irregular, cauliflower-like appearance** and can recur even after removal, making it a challenging condition to manage. *Vocal nodule* - Vocal nodules are typically **bilateral, symmetrical lesions** located at the junction of the anterior and middle thirds of the vocal cords. - They are usually **smooth, small, and whitish**, resulting from chronic vocal abuse, unlike the irregular and multiple growths seen in the image. *Vocal polyp* - Vocal polyps are typically **unilateral lesions** that can appear as sessile or pedunculated masses on a vocal cord. - They are often **larger than nodules** and may have a reddish or gelatinous appearance, but they usually occur singly, not as multiple diffuse growths like those pictured. *TB of vocal cords* - Tuberculosis of the vocal cords often presents with **ulcerative lesions**, granulomas, or diffuse inflammation, and may be accompanied by other signs of pulmonary TB. - The lesions caused by TB are generally **not papillomatous** or wart-like in nature, differentiating them from the appearance in the image.
Question 9: The image shows which of the following tests being performed? (Recent NEET Pattern 2016-17)
- A. A= Indirect laryngoscopy, B= Spatula test (Correct Answer)
- B. A= Posterior rhinoscopy, B= Spatula test
- C. A= Direct laryngoscopy, B= Spatula test
- D. A= Anterior rhinoscopy, B= Spatula test
Explanation: ***A= Indirect laryngoscopy, B= Spatula test*** - Image A depicts a mirror being used to visualize the larynx through the oral cavity, which is characteristic of **indirect laryngoscopy**. - Image B shows a spatula being used to apply pressure to the tongue or jaw while observing for a reflex action, which is consistent with the **spatula test** for tetanus. *A= Posterior rhinoscopy, B= Spatula test* - **Posterior rhinoscopy** involves visualizing the nasopharynx via a mirror placed behind the soft palate, which is not what is shown in Image A. - While Image B correctly shows a spatula test, Image A is clearly not a posterior rhinoscopy. *A= Direct laryngoscopy, B= Spatula test* - **Direct laryngoscopy** uses a laryngoscope to directly visualize the larynx without a mirror, often requiring sedation, which differs from the technique in Image A. - Image A shows the use of a mirror for visualization, thus ruling out direct laryngoscopy. *A= Anterior rhinoscopy, B= Spatula test* - **Anterior rhinoscopy** involves examining the anterior nasal cavity using a nasal speculum, which is not depicted in Image A. - Image A shows examination of the oral cavity and pharynx with a mirror, not the anterior nasal cavity.
Question 10: Which part of the larynx is most commonly involved in tuberculosis (TB)?
- A. Anterior
- B. Posterior (Correct Answer)
- C. Middle
- D. Anywhere
Explanation: ***Posterior*** - The **posterior larynx**, specifically the **arytenoids** and **interarytenoid area**, is the most common site for tuberculosis involvement. - This region is susceptible due to its rich **lymphatic supply** and direct exposure to infected secretions from the lungs. *Anterior* - While TB can affect any part of the larynx, the **anterior laryngeal structures** are less frequently the primary site of involvement. - The vocal cords, which are in the anterior-middle aspect, are less commonly affected initially compared to the posterior structures. *Middle* - The middle part of the larynx, including the **vocal cords**, is not the predominant site for initial tuberculous lesions. - Involvement here often occurs as the disease progresses from more commonly affected areas. *Anywhere* - Although TB can theoretically affect any part of the larynx, it demonstrates a strong predilection for the **posterior laryngeal region**. - Stating "anywhere" does not accurately reflect the statistically significant preference for specific anatomical sites.
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