Phonosurgery Techniques — MCQs
Which of the following changes in voice is not produced as a result of external laryngeal nerve injury post thyroidectomy?
After periodontal flap surgery, a patient is recalled for a maintenance visit in how many days?
What is the most appropriate anaesthesia technique for microlaryngoscopy?
A high tracheostomy may be indicated in:
All of the following are true about spasmodic dysphonia except which of the following?
What are the characteristics of reversible pulpitis?
Using a small fine probe, a single lactiferous duct is excised. What is the name of the procedure:
The voice is not affected in which of the following conditions?
A patient complains of sharp shooting pain in the pharynx and tonsil. On examination, a trigger zone is found in the tonsillar area. What is the diagnosis?
A young man whose voice has not been broken is called:
Phonosurgery Techniques Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: After periodontal flap surgery, a patient is recalled for a maintenance visit in how many days?
- A. 1 to 2 weeks (Correct Answer)
- B. 2 weeks
- C. 3 months
- D. 1 week
Explanation: ***1 to 2 weeks*** - A recall visit within **1 to 2 weeks** after periodontal flap surgery is crucial for assessing initial healing, removing sutures, and providing post-operative instructions. - This timeframe allows for early detection of complications, evaluation of patient compliance, and re-enforcement of oral hygiene practices. *1 week* - While an early check-up can be beneficial, 1 week might be slightly too soon for complete initial healing and suture removal in all cases, especially if there's significant inflammation or swelling. - Suture removal is typically recommended around 7-10 days, making the slightly broader 1-2 week window more appropriate. *2 weeks* - Though 2 weeks falls within the acceptable range, a slightly earlier visit (e.g., 10 days) would be ideal to address any issues promptly and remove sutures before they become embedded or cause irritation. - Waiting the full 14 days might delay intervention for minor complications that could be managed earlier. *3 months* - A 3-month recall is typically a **maintenance phase** visit for established periodontal health, not for the immediate post-operative assessment following flap surgery. - Significant issues could develop or worsen over 3 months if not addressed during the critical initial healing period.
Question 3: What is the most appropriate anaesthesia technique for microlaryngoscopy?
- A. Jet ventilation with TIVA
- B. Conventional endotracheal intubation (Correct Answer)
- C. Apneic technique with TIVA
- D. Laryngeal mask airway with spontaneous ventilation
Explanation: ***Conventional endotracheal intubation*** - While other techniques exist, **conventional endotracheal intubation** remains a widely accepted and often preferred method for microlaryngoscopy due to its ability to provide a secure airway, excellent surgical exposure, and controlled ventilation. - This technique allows for adequate **oxygenation and ventilation** during the procedure, which can be prolonged, and it protects the airway from **blood and secretions**. *Jet ventilation with TIVA* - **Jet ventilation** can provide an unobstructed laryngeal view and may be used, but it carries risks such as barotrauma and aspiration, and can cause difficulty with **CO2 clearance**. - While **total intravenous anesthesia (TIVA)** is suitable, the ventilation technique itself may not be the most appropriate primary choice due to its potential complications. *Apneic technique with TIVA* - The **apneic technique** (apneic oxygenation) may offer an unobstructed surgical field but is limited by the duration an individual can be safely apneic without hypercapnia or desaturation and a lack of control over ventilation for longer procedures. - Although **TIVA** is a good anesthetic choice, relying solely on an apneic period for the whole procedure may not be the safest or most practical method for many microlaryngoscopies. *Laryngeal mask airway with spontaneous ventilation* - A **laryngeal mask airway (LMA)** may provide a good view for some laryngeal procedures but does not offer the same level of airway protection against aspiration as an endotracheal tube. - **Spontaneous ventilation** with an LMA might not provide adequate control over gas exchange, especially if the procedure is prolonged or deep anesthesia is required.
Question 4: 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 5: All of the following are true about spasmodic dysphonia except which of the following?
- A. It may be of adductor or abductor type
- B. Adductor type is characterized by a strained or strangled voice.
- C. It is not a type of focal laryngeal dystonia. (Correct Answer)
- D. Abductor type is characterized by a breathy quality of voice.
Explanation: ***Correct Answer: "It is not a type of focal laryngeal dystonia" - This statement is FALSE (the exception)*** - **Spasmodic dysphonia IS a form of focal laryngeal dystonia**, characterized by involuntary spasms of the laryngeal muscles during speech. - Its classification as a **dystonia** underscores its neurological origin affecting specific muscle groups. - This is the correct answer because the question asks for the FALSE statement ("except"). *Incorrect Option: "It may be of adductor or abductor type" - This is TRUE* - **Spasmodic dysphonia** can present in two main forms: **adductor spasmodic dysphonia** and **abductor spasmodic dysphonia**. - These types are distinguished by whether the vocal folds spasm in an adducted (closed) or abducted (open) position. *Incorrect Option: "Abductor type is characterized by a breathy quality of voice" - This is TRUE* - In **abductor spasmodic dysphonia**, abrupt, involuntary spasms cause the vocal folds to open too widely, leading to air escaping during phonation. - This excessive air leakage results in a **breathy** or whispered voice quality, often with voice breaks. *Incorrect Option: "Adductor type is characterized by a strained or strangled voice" - This is TRUE* - **Adductor spasmodic dysphonia** involves involuntary spasms that cause the vocal folds to clamp shut too tightly and frequently. - This excessive vocal fold adduction results in a **strained, strangled, or choked** vocal quality, with sudden voice stoppages.
Question 6: What are the characteristics of reversible pulpitis?
- A. Aggravated by heat and may be relieved by cold
- B. Aggravated by cold and may be relieved by heat
- C. No reaction to hot and cold, indicating necrosis
- D. Reacts to electric pulp tester (Correct Answer)
Explanation: ***Reacts to electric pulp tester*** - In **reversible pulpitis**, the pulp is still vital and responsive, thus it will react to an **electric pulp tester** (EPT) with a sharp, transient pain at a lower current. - The sensation elicited by EPT indicates the presence of nerve fibers and a viable pulp, consistent with a reversible condition. *Aggravated by heat and may be relieved by cold* - This symptom profile, where pain is **aggravated by heat** and **relieved by cold**, is characteristic of **irreversible pulpitis**, not reversible pulpitis. - The relief with cold often indicates a build-up of pressure within the pulp that is temporarily alleviated by the vasoconstrictive effect of cold. *Aggravated by cold and may be relieved by heat* - While some mild, transient cold sensitivity can occur in **reversible pulpitis**, severe or prolonged cold sensitivity is more indicative of irreversible pulpitis. Relief with heat is not a typical characteristic of reversible pulpitis and would be very unusual for any pulpitis. - This pattern of discomfort is not a direct characteristic of reversible pulpitis; reversible pulpitis typically presents with **sharp, transient pain to cold** that resolves quickly. *No reaction to hot and cold, indicating necrosis* - A lack of reaction to thermal stimuli (hot and cold) is indicative of a **necrotic pulp**, meaning the pulp tissue has died. - In **reversible pulpitis**, the pulp is inflamed but still vital, and therefore will react to thermal stimuli, usually with a sharp, transient pain to cold.
Question 7: Using a small fine probe, a single lactiferous duct is excised. What is the name of the procedure:
- A. Microdochectomy (Correct Answer)
- B. Hadfield operation
- C. Webster operation
- D. Macrodochectomy
Explanation: ***Microdochectomy*** - This procedure involves the **excision of a single, lactiferous duct** often identified using a fine probe or ductoscope. - It is typically performed to investigate or treat **pathological nipple discharge** originating from a specific duct. *Hadfield operation* - This is a more extensive procedure known as a **total duct excision** or **subareolar duct excision**. - It involves the removal of **all major lactiferous ducts** under the nipple, not just a single one. *Webster operation* - The Webster operation refers to an **inferior pedicle reduction mammoplasty** technique. - It is a type of **breast reduction surgery** and is not related to the excision of an isolated lactiferous duct. *Macrodochectomy* - This term is **not a recognized medical procedure** in the context of duct excision. - While "macro" implies large, it does not describe a specific surgical technique for duct removal.
Question 8: 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).
Question 9: A patient complains of sharp shooting pain in the pharynx and tonsil. On examination, a trigger zone is found in the tonsillar area. What is the diagnosis?
- A. Sphenopalatine neuralgia
- B. Paratrigeminal neuralgia
- C. Glossopharyngeal neuralgia (Correct Answer)
- D. Trigeminal neuralgia
Explanation: **Explanation:** The clinical presentation of **sharp, shooting (paroxysmal) pain** localized to the **pharynx and tonsillar area**, initiated by a **trigger zone** in the tonsil, is the classic hallmark of **Glossopharyngeal Neuralgia**. **1. Why Glossopharyngeal Neuralgia is correct:** This condition involves the 9th cranial nerve. The pain is typically unilateral and occurs in the distribution of the glossopharyngeal nerve (posterior third of the tongue, tonsillar fossa, pharynx, and beneath the angle of the jaw). Common triggers include swallowing, talking, coughing, or touching the tonsillar area. **2. Why other options are incorrect:** * **Sphenopalatine neuralgia (Sluder’s Neuralgia):** Characterized by pain in the lower face, nose, and orbit, often associated with nasal congestion or rhinorrhea, rather than pharyngeal triggers. * **Paratrigeminal neuralgia (Raeder’s Syndrome):** Presents as trigeminal pain (usually V1/V2 distribution) accompanied by oculosympathetic palsy (Horner’s syndrome). * **Trigeminal neuralgia (Tic Douloureux):** The most common facial neuralgia, but the pain is located in the distribution of the 5th cranial nerve (usually maxillary or mandibular branches). Trigger zones are typically on the skin of the face or the gingiva, not the pharynx. **High-Yield Clinical Pearls for NEET-PG:** * **Eagle’s Syndrome:** A key differential diagnosis where an elongated styloid process irritates the glossopharyngeal nerve, causing similar pain. * **Treatment:** Medical management is the first line, primarily using **Carbamazepine**. * **Surgical Management:** If medical therapy fails, **Microvascular Decompression (MVD)** of the 9th nerve or rhizotomy is performed. * **Vagal Association:** In rare cases, glossopharyngeal neuralgia can trigger the carotid sinus reflex, leading to bradycardia or syncope.
Question 10: A young man whose voice has not been broken is called:
- A. Puberphonia (Correct Answer)
- B. Androphonia
- C. Plica ventricularis
- D. Functional aphonia
Explanation: **Explanation:** **Puberphonia** (also known as Mutational Falsetto) is a functional voice disorder where a male continues to use a high-pitched pre-pubertal voice despite having a normal, adult-sized larynx. During puberty, the male larynx grows significantly under the influence of testosterone, and the vocal cords lengthen and thicken. Puberphonia occurs when the individual resists this change, often due to psychological factors or difficulty adjusting to the new pitch, resulting in the persistent use of the "unbroken" voice. **Analysis of Incorrect Options:** * **Androphonia:** This refers to a female having an abnormally low-pitched, masculine voice. It is often caused by virilization (e.g., hormonal therapy or tumors) or Reinke’s edema. * **Plica Ventricularis (Ventricular Dysphonia):** This occurs when the false vocal cords (ventricular folds) are used for phonation instead of the true vocal cords. It results in a rough, low-pitched, and strained voice. * **Functional Aphonia:** This is a conversion disorder where the patient speaks only in a whisper despite having normal laryngeal anatomy and adduction during coughing. It is typically triggered by emotional stress. **High-Yield Clinical Pearls for NEET-PG:** * **Laryngeal Findings:** In puberphonia, the larynx is anatomically normal. On stroboscopy, the vocal cords are often tense and thin. * **Gutzmann’s Test:** This is the diagnostic/therapeutic maneuver where downward pressure is applied on the thyroid cartilage to relax the vocal cords, resulting in a lower pitch. * **Treatment:** The primary treatment is **Voice Therapy (Speech therapy)**, specifically the "Glottal Fry" technique. Type 3 Thyroplasty (Relaxation Thyroplasty) is reserved for resistant cases.
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