Laryngeal Framework Surgery — MCQs
Laryngeal mask airway [LMA] is contraindicated in?
A high tracheostomy may be indicated in:
During thyroidectomy, which nerve, if damaged, can cause a hoarse voice?
Emergency tracheostomy is not indicated in
During thyroidectomy, damage to which nerve leads to loss of high-pitched voice?
The primary goal of Type 1 thyroplasty is:
All of the following are true about Spasmodic Dysphonia except which of the following?
Which of the following steps in thyroid surgery is least likely to result in hoarseness of voice?
Which part of the larynx is most commonly involved in tuberculosis (TB)?
The voice is not affected in which of the following conditions?
Laryngeal Framework Surgery Indian Medical PG Practice Questions and MCQs
Question 1: Laryngeal mask airway [LMA] is contraindicated in?
- A. Ocular surgeries
- B. Pregnant female (Correct Answer)
- C. Difficult airways
- D. In CPR
Explanation: ***Pregnant female*** - **Pregnant patients** are at an increased risk of **gastric reflux and aspiration pneumonitis** due to decreased lower esophageal sphincter tone and increased intra-abdominal pressure. - The LMA does not provide a secure airway seal against aspiration, making it contraindicated in cases where **aspiration risk is high**, such as pregnancy or full stomach. *Difficult airways* - The LMA is often considered a **rescue device** in difficult airway algorithms when tracheal intubation fails. - It can be used as a conduit for **fiberoptic intubation** or as a temporary airway while preparing for a definitive airway. *Ocular surgeries* - LMAs are generally suitable for ocular surgeries as they provide a stable airway without the use of a mask, which can obstruct the surgical field. - They tend to cause **less coughing and straining** upon insertion and maintenance compared to endotracheal tubes, which is beneficial in preventing increases in intraocular pressure. *In CPR* - The LMA can be an effective airway device during **cardiopulmonary resuscitation (CPR)** when endotracheal intubation is not immediately feasible. - It provides a relatively quick and easy way to establish an airway, facilitate ventilation, and reduce the risk of gastric insufflation during chest compressions.
Question 2: A high tracheostomy may be indicated in:
- A. Advanced carcinoma of the larynx
- B. Severe bilateral vocal cord paralysis (Correct Answer)
- C. Chronic scleroma involving the larynx
- D. Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)
Explanation: ***Severe bilateral vocal cord paralysis*** - **High tracheostomy** may be indicated in severe bilateral vocal cord paralysis, particularly when both cords are paralyzed in the **median (adducted) position**, causing critical airway obstruction. - A high tracheostomy is performed at the level of the **2nd or 3rd tracheal ring**, closer to the site of obstruction at the glottic level, providing immediate airway access. - This can serve as temporary relief while definitive treatments like **arytenoidectomy, cordectomy, or vocal cord lateralization** are planned. - In emergency situations, high tracheostomy or cricothyroidotomy may be life-saving. *Advanced carcinoma of the larynx* - High tracheostomy is **contraindicated** in laryngeal carcinoma as it may: - Transect through tumor tissue - Cause tumor seeding in the tracheal stoma - Compromise subsequent **total laryngectomy** procedures - **Low tracheostomy** (below the tumor, at 4th-5th tracheal ring) is the standard approach to secure the airway while avoiding tumor interference. *Chronic scleroma involving the larynx* - Scleroma typically causes **subglottic stenosis** and involves extensive tracheal disease. - **Low tracheostomy** is preferred to bypass the diseased area completely. - A high tracheostomy would be too close to the pathological process, risking inadequate airway and complications. *Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)* - Tracheostomy is generally **avoided** in RRP due to the significant risk of **seeding papillomas** into the tracheal stoma and lower airways. - Management focuses on **repeated endoscopic laser ablation** or surgical excision to preserve laryngeal function. - If tracheostomy is absolutely necessary, meticulous technique and close follow-up are required.
Question 3: During thyroidectomy, which nerve, if damaged, can cause a hoarse voice?
- A. Recurrent laryngeal; loops under aorta/subclavian (Correct Answer)
- B. Superior laryngeal; with superior thyroid artery
- C. Glossopharyngeal; along posterior thyroid
- D. Hypoglossal; inferior to thyroid
Explanation: ***Recurrent laryngeal; loops under aorta/subclavian*** - The **recurrent laryngeal nerve (RLN)** innervates most of the intrinsic muscles of the larynx, including the **posterior crico-arytenoid muscle**, which is responsible for abducting the vocal cords. - Damage to the RLN during thyroidectomy can lead to **vocal cord paralysis**, resulting in a hoarse voice, stridor, or aspiration. *Superior laryngeal; with superior thyroid artery* - The **superior laryngeal nerve (SLN)** branches into external and internal laryngeal nerves. The **external laryngeal nerve** runs with the **superior thyroid artery** and innervates the **cricothyroid muscle**, which is responsible for tensioning the vocal cords. - Damage to the SLN can cause subtle changes in voice pitch and reduced vocal range but typically does not cause hoarseness or vocal cord paralysis, which is more characteristic of RLN injury. *Glossopharyngeal; along posterior thyroid* - The **glossopharyngeal nerve (CN IX)** provides sensory innervation to the posterior third of the tongue, tonsils, pharynx, and middle ear, and motor innervation to the stylopharyngeus muscle. - It is not directly related to vocal cord function or hoarseness as a result of thyroid surgery. *Hypoglossal; inferior to thyroid* - The **hypoglossal nerve (CN XII)** innervates all extrinsic and intrinsic muscles of the tongue, controlling tongue movement. - Damage to the hypoglossal nerve would affect speech articulation and swallowing but not directly cause hoarseness or vocal cord paralysis.
Question 4: Emergency tracheostomy is not indicated in
- A. Bilateral vocal cord paralysis
- B. Foreign body larynx
- C. Acute severe asthma (Correct Answer)
- D. Stridor due to laryngeal growth
Explanation: ***Acute severe asthma*** - While life-threatening, acute severe asthma is primarily managed with **bronchodilators**, **steroids**, and potentially **non-invasive or invasive ventilation**. - **Tracheostomy** is generally reserved for situations involving upper airway obstruction that cannot be managed by other means, which is not the primary issue in asthma. *Bilateral vocal cord paralysis* - This condition can cause severe **upper airway obstruction** due to the adduction of both vocal cords. - In an emergency setting, a tracheostomy may be life-saving to bypass the obstructed larynx. *Foreign body larynx* - An obstructing **foreign body in the larynx** can lead to immediate and complete airway compromise. - If efforts like the **Heimlich maneuver** or direct laryngoscopy with removal fail, an emergency tracheostomy might be necessary. *Stridor due to laryngeal growth* - A laryngeal growth causing **stridor** indicates significant airway narrowing, which can acutely worsen and lead to respiratory distress. - In cases of severe or rapidly progressive obstruction, an **emergency tracheostomy** is needed to secure the airway below the level of the growth.
Question 5: During thyroidectomy, damage to which nerve leads to loss of high-pitched voice?
- A. External branch of the superior laryngeal nerve (Correct Answer)
- B. Hypoglossal nerve
- C. Vagus nerve
- D. Recurrent laryngeal nerve
Explanation: ***External branch of the superior laryngeal nerve*** - The **external branch of the superior laryngeal nerve** innervates the **cricothyroid muscle**, which is responsible for tensing the vocal cords. - Damage to this nerve paralyzes the cricothyroid muscle, leading to an inability to tense the vocal cords, resulting in a **monotonous voice** and **loss of high-pitched tones**. *Hypoglossal nerve* - The **hypoglossal nerve (CN XII)** controls the muscles of the **tongue**, affecting articulation and swallowing, but not vocal pitch directly. - Damage primarily causes **tongue deviation** and **difficulty with speech (dysarthria)** and swallowing. *Vagus nerve* - The **vagus nerve (CN X)** gives rise to both the **superior laryngeal nerve** and the **recurrent laryngeal nerve**. - While damage to the vagus nerve trunk would affect vocalization, the question specifically asks about loss of high-pitched voice, which points to a more localized injury to one of its branches. *Recurrent laryngeal nerve* - The **recurrent laryngeal nerve** innervates most of the intrinsic laryngeal muscles, including the **thyroarytenoid** and **posterior cricoarytenoid muscles**, primarily affecting vocal cord adduction and abduction. - Damage typically causes **hoarseness** due to vocal cord paralysis, and in severe cases, difficulty breathing, but it does not specifically lead to the *loss of high-pitched voice* as directly as superior laryngeal nerve damage.
Question 6: The primary goal of Type 1 thyroplasty is:
- A. Lateralisation of vocal cord
- B. Medialisation of vocal cord (Correct Answer)
- C. Vocal cord shortening
- D. Vocal cord lengthening
Explanation: ***Medialisation of vocal cord*** - **Type 1 thyroplasty** (also known as medialization laryngoplasty) aims to push the vocal cord medially, improving vocal cord closure - This procedure is primarily used to treat **unilateral vocal cord paralysis** or paresis, where one vocal cord cannot move sufficiently to meet the other for voice production - By medializing the paralyzed vocal cord, the procedure restores glottic competence and improves voice quality *Lateralisation of vocal cord* - Lateralisation of the vocal cord would worsen a glottal gap and lead to a more breathy voice or aphonia - This is generally not a desired outcome for voice improvement but might be considered in cases of severe airway obstruction (e.g., Type 2 thyroplasty for bilateral vocal cord paralysis) *Vocal cord shortening* - Vocal cord shortening primarily affects pitch, typically lowering it, and is achieved through procedures like cricothyroid approximation or by altering tension - This is not the main goal of Type 1 thyroplasty, which focuses on closure rather than length *Vocal cord lengthening* - Vocal cord lengthening is done to increase vocal pitch, often through procedures that increase vocal cord tension, such as cricothyroid approximation - This is a separate surgical goal from improving vocal cord apposition, which is the aim of Type 1 thyroplasty
Question 7: All of the following are true about Spasmodic Dysphonia except which of the following?
- A. It may be of adductor or abductor type
- B. It is focal Laryngeal dystonia
- C. Adductor type is characterized by Breathiness. (Correct Answer)
- D. Abductor type is characterized by Whispering quality of voice
Explanation: ***Adductor type is characterized by Breathlessness.*** - Breathiness in spasmodic dysphonia is characteristic of the **abductor type**, where the vocal folds frequently open, allowing air to escape during phonation. - The **adductor type** is characterized by a strained, choked, or squeezed voice quality due to excessive vocal fold closure. *It may be of adductor or abductor type* - Spasmodic dysphonia is indeed classified into **adductor and abductor types**, depending on which laryngeal muscles are predominantly affected. - The **adductor type** is more common, involving excessive vocal fold closure, while the abductor type involves excessive opening. *Abductor type is characterized by Whispering quality of voice* - The **abductor type** of spasmodic dysphonia often leads to a breathy or whispering quality because the vocal folds abduct (open) involuntarily during speech. - This results in a lack of proper vocal fold closure necessary for clear voice production. *It is focal Laryngeal dystonia* - Spasmodic dysphonia is considered a **focal dystonia**, specifically affecting the muscles of the larynx used for speech. - Dystonias are neurological movement disorders characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive, movements or postures.
Question 8: Which of the following steps in thyroid surgery is least likely to result in hoarseness of voice?
- A. Ligation of superior thyroid artery
- B. Removal of the tubercle of Zuckerkandl
- C. Division of strap muscles (Correct Answer)
- D. Dissection of Beahrs triangle
Explanation: ***Division of strap muscles*** - Dividing the **strap muscles** (sternohyoid, sternothyroid, omohyoid) provides surgical access to the thyroid gland but does not directly involve structures critical for vocal cord function. - While it may cause temporary **neck discomfort** or altered neck contour, it is least likely to lead to hoarseness. *Ligation of superior thyroid artery* - Ligation of the **superior thyroid artery** occurs in close proximity to the **external laryngeal nerve**, a branch of the superior laryngeal nerve. - Damage to the external laryngeal nerve can cause subtle voice changes due to **cricothyroid muscle paralysis**, impacting pitch. *Removal of the tubercle of Zuckerkandl* - The **tubercle of Zuckerkandl** is a posterior extension of the thyroid gland, often lying close to the **recurrent laryngeal nerve**. - Its removal requires careful dissection in an area where the recurrent laryngeal nerve is vulnerable to **traction or direct injury**, which can cause hoarseness. *Dissection of Beahrs triangle* - **Beahrs triangle** is an anatomical landmark formed by the common carotid artery, inferior border of the thyroid lobe, and the recurrent laryngeal nerve. - Dissection within this triangle carries a high risk of **recurrent laryngeal nerve injury**, leading to vocal cord paralysis and significant hoarseness.
Question 9: 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.
Question 10: The voice is not affected in which of the following conditions?
- A. Unilateral abductor palsy (Correct Answer)
- B. Unilateral adductor palsy
- C. Partial abductor palsy
- D. Total adductor palsy
Explanation: In phoniatrics, the quality of voice depends on the ability of the vocal cords to meet in the midline (**adduction**) for vibration. ### **Explanation of the Correct Answer** **A. Unilateral abductor palsy:** In this condition, the affected vocal cord is paralyzed in the **median (midline) position** because it cannot move outward (abduct). Since the paralyzed cord is already at the midline, the healthy cord can easily meet it during phonation. As a result, the glottic gap is closed perfectly, and the **voice remains normal**. This condition is often asymptomatic and may only present with mild exertional dyspnea (stridor). ### **Why the Other Options are Incorrect** * **B. Unilateral adductor palsy:** The affected cord remains in the **paramedian or lateral position** and cannot move to the midline. This creates a large glottic gap during speech, leading to a **breathy, weak voice (hoarseness)**. * **C. Partial abductor palsy:** According to **Semon’s Law**, in progressive lesions of the recurrent laryngeal nerve, abductor fibers are injured first. This results in the cord being stuck in a position that interferes with the symmetry of vibration, leading to varying degrees of **hoarseness**. * **D. Total adductor palsy:** This involves a complete failure of the cords to approximate, leading to significant **aphonia** (loss of voice) or severe breathiness. ### **Clinical Pearls for NEET-PG** * **Semon’s Law:** In progressive recurrent laryngeal nerve (RLN) injury, abductors (Posterior Cricoarytenoid) are paralyzed before adductors. * **Wagner and Grossman Hypothesis:** If the Superior Laryngeal Nerve (SLN) is intact, the cricothyroid muscle keeps the paralyzed cord in the **paramedian** position. * **Position of Cords:** * Unilateral RLN palsy: Paramedian position. * Bilateral RLN palsy: Median/Paramedian (Airway emergency, but voice is often good). * Combined RLN + SLN palsy: **Cadaveric position** (Intermediate position).
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