Spasmodic Dysphonia — MCQs
Neurogenic cause of dysphagia includes following except:
Treatment of choice in early vocal nodule is:
A patient presents with hoarseness and laryngoscopy reveals a warty, cauliflower-like growth on the vocal cord. Identify the most likely lesion.
In acoustic neuroma, which cranial nerve is involved earliest?
A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?
The voice in a patient with bilateral abductor paralysis of the larynx is most likely to be?
Dysdiadochokinesia refers to:
All are true about spasmodic dysphonia EXCEPT:
All of the following are true about Spasmodic Dysphonia except which of the following?
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?
Spasmodic Dysphonia Indian Medical PG Practice Questions and MCQs
Question 1: Neurogenic cause of dysphagia includes following except:
- A. Tetany (Correct Answer)
- B. Multiple sclerosis
- C. Tetanus
- D. Parkinson's disease
Explanation: ***Tetany*** - **Tetany** is characterized by **involuntary muscle contractions** due to electrolyte imbalances (e.g., hypocalcemia) or toxins, primarily affecting peripheral nerves and muscles, not typically considered a neurogenic cause of dysphagia in the context of central nervous system disorders. - While severe muscle spasms can impair swallowing, the underlying pathophysiology of tetany is distinct from the neurological deficits seen in conditions like MS or Parkinson's regarding direct innervation of swallowing muscles. *Multiple sclerosis* - **Multiple sclerosis** is a demyelinating disease of the central nervous system that can affect cranial nerves and brainstem pathways involved in swallowing, leading to **neurogenic dysphagia**. - Lesions in areas controlling **pharyngeal muscles** or **motor planning** for swallowing directly impair the neurological control of this process. *Tetanus* - **Tetanus** is caused by a neurotoxin (tetanospasmin) that blocks inhibitory neurotransmitters, leading to **severe muscle spasms** and rigidity, including those of the jaw (trismus) and pharynx. - The resulting **spastic paralysis** directly interferes with the coordinated muscle movements required for swallowing, making it a neurogenic cause of dysphagia. *Parkinson's disease* - **Parkinson's disease** is a progressive neurodegenerative disorder affecting the basal ganglia, leading to motor symptoms including **bradykinesia**, rigidity, and tremor [1]. - It commonly causes **neurogenic dysphagia** due to impaired coordination, reduced pharyngeal motility, and delayed swallow reflex, impacting all phases of swallowing [2].
Question 2: Treatment of choice in early vocal nodule is:
- A. Voice rest and speech therapy (Correct Answer)
- B. Cryotherapy
- C. Microlaryngoscopic removal
- D. Radical excision
Explanation: ***Voice rest and speech therapy*** - In cases of **early vocal nodules**, conservative management with **voice rest** and **speech therapy** is the primary treatment. - This approach aims to reduce vocal trauma and modify vocal habits, allowing the nodules to resolve naturally without surgical intervention. *Cryotherapy* - **Cryotherapy** involves freezing and destroying abnormal tissue and is not a standard treatment for vocal nodules. - Its application is more common for superficial lesions, such as certain skin cancers or warts, not benign vocal cord growths. *Microlaryngoscopic removal* - Although **microlaryngoscopic removal** is an option for vocal nodules, it is usually reserved for larger, more established nodules that have not responded to conservative measures. - This is an invasive procedure and is not the **first-line treatment** for early-stage nodules where non-surgical methods are often effective. *Radical excision* - **Radical excision** is a surgical technique for removing lesions, but it is not typically applied to vocal nodules. - The term "radical excision" is often used in the context of oncological procedures involving extensive tissue removal, not benign vocal cord lesions.
Question 3: A patient presents with hoarseness and laryngoscopy reveals a warty, cauliflower-like growth on the vocal cord. Identify the most likely lesion.
- A. Laryngeal papilloma (Correct Answer)
- B. Laryngeal malignancy
- C. Tracheomalacia
- D. Reinke’s edema
Explanation: ***Laryngeal papilloma*** - **Hoarseness** and a **warty, cauliflower-like growth** on the vocal cord are classic descriptions of a laryngeal papilloma, often caused by **HPV infection**. - These lesions can be solitary or multiple, and while benign, they can recur and cause voice changes and respiratory obstruction. *Laryngeal malignancy* - While hoarseness is a common symptom of laryngeal malignancy, the description of a **"warty, cauliflower-like growth"** is more characteristic of a papilloma than most typical carcinomas, which might appear more ulcerative or infiltrative. - Malignancies are more commonly associated with risk factors like **smoking and alcohol use**, and often present with other symptoms like dysphagia or weight loss. *Tracheomalacia* - **Tracheomalacia** refers to softening of the tracheal cartilage, leading to airway collapse, typically causing stridor or respiratory distress. - It does not present as a **discrete growth** on the vocal cords but rather as a diffuse structural weakness of the trachea. *Reinke’s edema* - **Reinke's edema** (polypoid corditis) is characterized by a **gelatinous or fluid-filled swelling** of the vocal cords, usually associated with chronic irritation like smoking. - It presents as a swollen, boggy appearance of the vocal cords, not a warty or cauliflower-like growth.
Question 4: In acoustic neuroma, which cranial nerve is involved earliest?
- A. CN V
- B. CN VII
- C. CN VIII (Correct Answer)
- D. CN X
Explanation: ***CN VIII*** - An **acoustic neuroma** (also known as a **vestibular schwannoma**) originates from the **Schwann cells** of the **vestibulocochlear nerve (CN VIII)**. - Due to its origin, symptoms related to **hearing loss**, **tinnitus**, and **balance issues** (all functions of CN VIII) are typically the earliest to manifest [1]. *CN V* - The **trigeminal nerve (CN V)** is responsible for **facial sensation** and **mastication**. - Compression of CN V usually occurs in later stages of acoustic neuroma growth, leading to **facial numbness** or **pain**. *CN VII* - The **facial nerve (CN VII)** controls **facial expressions** and taste sensation in the anterior two-thirds of the tongue. - **Facial weakness** or **paralysis** due to CN VII involvement typically occurs after significant tumor growth, as the nerve runs adjacent to the acoustic neuroma [1]. *CN X* - The **vagus nerve (CN X)** is involved in diverse functions including **swallowing**, **speech**, and **autonomic regulation** of organs like the heart and digestive tract. - **Vagal nerve** symptoms such as **dysphagia** or **hoarseness** are extremely rare in acoustic neuromas and would indicate a very extensive tumor likely compressing structures much more distant from the primary site.
Question 5: A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?
- A. Direct laryngoscopy with biopsy (Correct Answer)
- B. MRI of neck
- C. CT scan of neck
- D. Radiotherapy
Explanation: ***Direct laryngoscopy with biopsy*** - A definitive diagnosis of a vocal cord mass requires **histological examination** to rule out malignancy, especially given the patient's risk factors (age, smoking) and symptoms (hoarseness, dysphagia, weight loss). - **Direct laryngoscopy** allows for a thorough, magnified view of the mass and precise biopsy collection, which is superior to flexible laryngoscopy alone for definitive diagnosis and staging. *MRI of neck* - While MRI can provide excellent soft tissue detail for **staging** a known malignancy, it cannot provide a **histological diagnosis**. - It would typically be performed after a biopsy confirms malignancy to assess the extent of the tumor and potential spread. *CT scan of neck* - A CT scan is useful for evaluating **bony involvement**, lymph node status, and tumor extension for **staging purposes**, but it is not a diagnostic tool for identifying the specific type of tissue or cell pathology. - Like MRI, a CT scan would generally follow a biopsy confirming malignancy. *Radiotherapy* - **Radiotherapy** is a treatment modality for laryngeal cancer, not a diagnostic step. - Initiating treatment without a definitive histological diagnosis of malignancy would be inappropriate and potentially harmful.
Question 6: 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 7: Dysdiadochokinesia refers to:
- A. Inability to Perform Rapid Alternating Movements (Correct Answer)
- B. Intention Tremor
- C. Tremor of the Eyeballs
- D. Failure of Progression in Talking
Explanation: ***Inability to Perform Rapid Alternating Movements*** - **Dysdiadochokinesia** is a neurological sign indicating an impaired ability to perform **rapid alternating movements**, such as pronation and supination of the forearms [1]. - It is a key indicator of **cerebellar dysfunction**, as the cerebellum is responsible for coordinating the rate, range, and force of movements [1]. *Intention Tremor* - An **intention tremor** is a tremor that worsens during purposeful movement towards a target, not a difficulty with alternating movements themselves. - While also a sign of **cerebellar damage**, it manifests as oscillations during voluntary action, distinct from dysdiadochokinesia. *Tremor of the Eyeballs* - This condition is known as **nystagmus**, which refers to involuntary rhythmic eye movements [2]. - While nystagmus can be associated with **cerebellar dysfunction**, it is a distinct sign separate from the ability to perform rapid alternating limb movements [2]. *Failure of Progression in Talking* - This symptom is characteristic of **dysarthria**, a motor speech disorder that impacts articulation, phonation, and prosody [2]. - While certain types of dysarthria can be linked to **cerebellar disease**, "failure of progression in talking" specifically describes speech difficulties, not the coordination of limb movements [2].
Question 8: All are true about spasmodic dysphonia EXCEPT:
- A. Responds well to botulinum toxin
- B. Adductor type is more common
- C. Usually bilateral involvement
- D. More common in children (Correct Answer)
Explanation: ***More common in children*** - Spasmodic dysphonia is primarily a disorder affecting **adults**, with onset typically occurring between the ages of 30 and 50 years. - It is **rarely seen in children**, and when voice disorders occur in children, they are usually due to other causes like vocal nodules or muscle tension dysphonia. *Responds well to botulinum toxin* - **Botulinum toxin (Botox) injections** into the laryngeal muscles are considered the **gold standard treatment** for spasmodic dysphonia. - It effectively paralyzes the spasmodic muscles, providing **significant symptomatic relief** for several months. *Adductor type is more common* - The **adductor type**, characterized by a strained, choked, or squeezed voice quality, accounts for approximately **85-90% of all spasmodic dysphonia cases**. - This is due to involuntary spasms that cause the vocal cords to slam together too tightly. *Usually bilateral involvement* - Spasmodic dysphonia primarily involves the **laryngeal intrinsic muscles**, and the spasms are often **bilateral**, affecting muscles on both sides of the larynx. - While one side might be more affected, the underlying neurological dysfunction typically manifests with **bilateral muscle activation abnormalities**.
Question 9: 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 10: 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.
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