Diseases of the Larynx Practice Questions

Q: What is the most common cause of stridor in children?

Laryngomalacia. **Explanation:** **Laryngomalacia** is the most common cause of congenital stridor in infants and the most common congenital anomaly of the larynx. It is characterized by an inward collapse of the supraglottic structures (epiglottis, aryepiglottic folds) during inspiration, leading to a characteristic high-pitched **inspiratory stridor**. The symptoms typically appear within the first two weeks of life, worsen with crying or feeding, and usually resolve spontaneously by 18–24 months as the laryngeal cartilage matures. **Analysis of Incorrect Options:** * **B. Congenital laryngeal paralysis:** This is the second most common cause of congenital stridor. It can be unilateral (often associated with birth trauma or cardiac anomalies) or bilateral (often associated with CNS issues like Arnold-Chiari malformation). * **C. Foreign body in larynx:** While a common cause of *acute* respiratory distress in toddlers, it is not the most common cause overall and typically presents with a sudden onset of choking and cough. * **D. Congenital laryngeal tumors:** These (such as subglottic hemangiomas) are rare. They typically present with progressive stridor and are not as prevalent as laryngomalacia. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Flexible fiberoptic laryngoscopy is the gold standard (shows "Omega-shaped" epiglottis). * **Positioning:** Stridor in laryngomalacia typically **improves in the prone position** and worsens in the supine position. * **Management:** Most cases are managed conservatively. Surgical intervention (**Supraglottoplasty**) is reserved for severe cases with failure to thrive or cor pulmonale.

Q: Hoarseness of voice occurs early in which of the following conditions?

Glottic carcinoma. **Explanation:** The correct answer is **Glottic carcinoma**. This is a high-yield concept in ENT based on the anatomical and physiological characteristics of the larynx. **1. Why Glottic Carcinoma is the correct answer:** The glottis consists of the true vocal cords. Since the primary function of the vocal cords is phonation, any mucosal irregularity, growth, or mass—even a very small one—immediately disrupts the smooth vibratory pattern and closure of the cords. This results in **hoarseness of voice** as the earliest presenting symptom. Because this symptom appears early, glottic tumors are often diagnosed at an early stage (T1), leading to a better prognosis. **2. Why the other options are incorrect:** * **Supraglottic Carcinoma:** The supraglottis (epiglottis, aryepiglottic folds, false cords) is a "roomy" area. Tumors here remain asymptomatic for a long time. They typically present late with symptoms like throat pain, dysphagia, or a "hot potato voice." Hoarseness only occurs if the tumor spreads downwards to involve the true vocal cords. * **Subglottic Carcinoma:** This is a rare site. Tumors here are often "silent" and usually present with **stridor** or airway obstruction rather than hoarseness, as the growth occurs below the level of the vocal cords. **Clinical Pearls for NEET-PG:** * **Lymphatic Drainage:** The glottis has practically **no lymphatic drainage**; hence, nodal metastasis is extremely rare in early glottic cancer. * **Supraglottis:** Has a rich lymphatic network, leading to a high incidence of bilateral cervical lymph node metastasis. * **Rule of Thumb:** Any patient with hoarseness of voice persisting for more than **3 weeks** must undergo indirect laryngoscopy (IDL) or fiberoptic laryngoscopy to rule out malignancy.

Q: What is the most common cause of unilateral left vocal cord palsy?

Trauma. **Explanation:** The most common cause of unilateral vocal cord palsy (specifically on the left side) is **Trauma**, with surgical trauma being the leading subtype. **Why Trauma is the Correct Answer:** The left recurrent laryngeal nerve (RLN) has a longer, more convoluted intrathoracic course compared to the right. It loops under the arch of the aorta before ascending in the tracheoesophageal groove. This extended anatomy makes it highly susceptible to injury during various surgeries, including thyroidectomy, esophagectomy, and especially cardiothoracic procedures (e.g., PDA ligation or lung resections). Statistically, surgical trauma remains the most frequent etiology in modern clinical practice. **Analysis of Incorrect Options:** * **Carcinoma of the thyroid:** While a significant cause of RLN palsy, it is less common than surgical trauma. If a patient presents with palsy *and* a thyroid mass, malignancy is highly suspected, but it is not the most common cause overall. * **Carcinoma of the esophagus:** This can cause palsy due to the nerve's proximity in the tracheoesophageal groove, but it is statistically less frequent than trauma. * **Idiopathic:** Historically, many cases were labeled idiopathic; however, with improved diagnostic imaging, most cases are now attributed to specific traumatic or neoplastic causes. **NEET-PG High-Yield Pearls:** * **Left vs. Right:** Left-sided palsy is more common than right-sided palsy (ratio ~2:1) due to the longer course of the left RLN. * **Ortner’s Syndrome:** Left RLN palsy caused by cardiovascular conditions (e.g., mitral stenosis leading to left atrial enlargement) is a classic exam favorite. * **Position of Cord:** In unilateral RLN palsy, the affected cord usually lies in the **paramedian position** because the cricothyroid muscle (supplied by the Superior Laryngeal Nerve) remains intact and adducts the cord.

Q: Which procedure should precede microlaryngoscopy?

Laryngoendoscopy. **Explanation:** Microlaryngoscopy (MLS) is a specialized procedure performed under general anesthesia using an operating microscope to visualize and operate on the vocal folds. However, before proceeding with the high-magnification view of the larynx, a **Laryngoendoscopy** (specifically, a direct laryngoscopy) must be performed. **Why Laryngoendoscopy is the correct answer:** The primary goal of performing a direct laryngoscopy before the microscope is introduced is to conduct a **comprehensive survey** of the entire laryngeal and perilaryngeal area (including the vallecula, epiglottis, and aryepiglottic folds). This ensures that no synchronous lesions or structural abnormalities are missed that might be outside the narrow field of view provided by the microscope. It also allows the surgeon to assess the ease of exposure and the stability of the larynx before committing to the microscopic phase. **Analysis of Incorrect Options:** * **Pharyngoscopy:** While the pharynx is visualized during the introduction of the laryngoscope, a formal pharyngoscopy is not a mandatory prerequisite for microlaryngoscopy unless a pharyngeal pathology is suspected. * **Esophagoscopy:** This is a separate procedure to visualize the esophagus. While it may be part of a "triple endoscopy" (panendoscopy) for cancer staging, it is not a routine requirement preceding MLS. * **Rhinoscopy:** This involves the examination of the nasal cavity and is unrelated to the surgical exposure required for laryngeal microsurgery. **High-Yield Clinical Pearls for NEET-PG:** * **Positioning:** Microlaryngoscopy is performed in the **Boyce’s position** (Barking Dog position)—neck flexed and head extended. * **Indication:** It is the gold standard for the excision of vocal nodules, polyps, and Reinke’s edema. * **Complication:** The most common minor complication is tongue numbness or dental injury; the most serious is laryngospasm upon extubation.

Q: Turban epiglottitis is a clinical finding in which of the following conditions?

Tubercular laryngitis. ### Explanation **Correct Option: A. Tubercular Laryngitis** Turban epiglottitis is a classic clinical sign of **secondary laryngeal tuberculosis**. In this condition, the epiglottis becomes markedly swollen and edematous due to infiltration by tuberculous granulomas and lymphatic obstruction. This uniform, pale swelling gives the epiglottis a rounded appearance resembling a **turban**. It is typically associated with active pulmonary tuberculosis, where infected sputum causes "surface infection" of the laryngeal mucosa. **Analysis of Incorrect Options:** * **B. Tubercular pharyngitis:** While TB can affect the pharynx, it usually presents as painful ulcerations (often on the tonsils or posterior wall) rather than the specific "turban" swelling of the epiglottis. * **C. Polypoid degeneration of vocal cord:** Also known as **Reinke’s edema**, this involves bilateral, diffuse swelling of the vocal folds (Reinke’s space), typically due to smoking or vocal abuse. It does not involve the epiglottis. * **D. Subglottic hemangioma:** This is a vascular malformation found below the vocal cords, presenting as inspiratory or biphasic stridor in infants. It does not produce epiglottic changes. **Clinical Pearls for NEET-PG:** * **Most common site in Laryngeal TB:** Posterior commissure (interarytenoid area). * **Classic Appearance:** "Mouse-nibbled" appearance of the vocal cords (due to ulceration). * **Symptoms:** Severe pain (odynophagia) referred to the ear via the vagus nerve (Arnold’s nerve) is a hallmark. * **Mamillated space:** The interarytenoid area often shows a "mamillated" or granular appearance. * **Treatment:** Standard Anti-Tubercular Therapy (ATT).

Q: The best way to diagnose laryngomalacia is:

Flexible fibreoptic laryngoscopy. ### Explanation **Laryngomalacia** is the most common congenital anomaly of the larynx and the leading cause of congenital stridor. It is characterized by "floppy" supraglottic structures that collapse inward during inspiration. **Why Option D is Correct:** The gold standard for diagnosis is **Flexible Fibreoptic Laryngoscopy (FFL)** performed while the patient is **awake and breathing spontaneously**. This allows the clinician to observe the dynamic collapse of the supraglottic tissues (such as omega-shaped epiglottis or shortened aryepiglottic folds) in real-time during the respiratory cycle. **Why Other Options are Incorrect:** * **Option A:** While symptoms (inspiratory stridor worsening when supine or crying) are suggestive, they cannot definitively differentiate laryngomalacia from other causes of stridor like vocal cord palsy or subglottic stenosis. * **Option B:** Soft tissue X-rays are useful for detecting radio-opaque foreign bodies or "steeple signs" in croup, but they cannot capture the dynamic soft tissue collapse characteristic of laryngomalacia. * **Option C:** Direct laryngoscopy under General Anaesthesia (GA) often utilizes muscle relaxants or positive pressure ventilation, which can mask the natural dynamic collapse of the airway, leading to a false-negative result. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** High-pitched inspiratory stridor that appears at 2–4 weeks of age, worsens in the supine position, and improves when prone. * **Key Findings on FFL:** 1. **Omega-shaped (Ω) epiglottis** (most common). 2. Shortened aryepiglottic folds. 3. Redundant/bulky arytenoid mucosa. * **Management:** Most cases (90%) are self-limiting and resolve by 18–24 months. **Supraglottoplasty** is the surgical treatment of choice for severe cases (e.g., failure to thrive, cor pulmonale, or severe apnea).

Q: What is the treatment of choice for T1N0M0 glottic carcinoma?

External beam radiotherapy. ### Explanation **Concept Overview:** T1N0M0 glottic carcinoma refers to a tumor limited to the vocal cords (with normal mobility) and no nodal or distant metastasis. The primary goal of treatment in early glottic cancer is **cure with preservation of voice quality.** **Why Option D is Correct:** **External Beam Radiotherapy (EBRT)** is considered the treatment of choice because it offers excellent local control rates (85-95%) while maintaining a superior post-treatment voice quality compared to traditional surgery. Since the vocal cords are not physically altered or excised, the mucosal wave is preserved, leading to a near-normal voice. **Analysis of Incorrect Options:** * **A. Surgery:** While **Transoral Laser Microsurgery (TLM)** is an equally effective alternative for T1 lesions, "Surgery" as a general term often implies cordectomy. Surgery is usually reserved for patients who cannot commit to daily radiation schedules or for recurrences. In most standard protocols, EBRT is preferred for its functional outcome. * **B. Brachytherapy:** This involves placing radioactive sources directly into the tissue. It is rarely used for glottic cancer due to the risk of cartilage necrosis and the technical difficulty of placement in the larynx. * **C. Chemotherapy:** Early-stage (T1/T2) glottic cancer is highly radiosensitive. Chemotherapy is reserved for advanced stages (T3/T4) as part of concurrent chemoradiation for organ preservation. **NEET-PG High-Yield Pearls:** * **Most common site** of laryngeal cancer: Glottis. * **Best prognosis** in laryngeal cancer: Glottic (due to sparse lymphatic drainage, leading to late metastasis). * **Earliest symptom** of glottic cancer: Hoarseness of voice. * **Treatment for T1/T2:** Radiotherapy or Laser Surgery (TLM). * **Treatment for T3/T4:** Concurrent Chemoradiotherapy or Total Laryngectomy.

Q: What is the advantage of flexible bronchoscopy?

All of the above. Flexible bronchoscopy is a versatile diagnostic and therapeutic tool in airway management. Unlike rigid bronchoscopy, which requires general anesthesia and specific neck positioning, the flexible fiberoptic scope offers several distinct advantages: **1. Awake Procedures (Option A):** Flexible bronchoscopy can be performed under local anesthesia (topical lidocaine) with or without conscious sedation. This is crucial for evaluating dynamic airway collapse (tracheomalacia) or performing "awake intubations" in patients with anticipated difficult airways. **2. Distal Reach (Option B):** Due to its small diameter and maneuverability (tip deflection), the flexible scope can navigate beyond the lobar bronchi into the **subsegmental bronchi**. This allows for distal biopsies, brushings, and bronchoalveolar lavage (BAL) in the periphery of the lung, which is impossible with a rigid scope. **3. Anatomical Versatility (Option C):** Rigid bronchoscopy requires "line-of-sight" access, necessitating neck extension and wide jaw opening. Flexible bronchoscopy can be performed via the nasal or oral route and is the preferred method for patients with **cervical spine instability, trismus (lockjaw), or micrognathia**. **Clinical Pearls for NEET-PG:** * **Gold Standard for Foreign Body Removal:** Rigid Bronchoscopy (due to better airway control and larger working channel). * **Gold Standard for Hemoptysis (Massive):** Rigid Bronchoscopy (better suctioning capability). * **Preferred for Peripheral Lesions:** Flexible Bronchoscopy. * **Key Contraindication:** Severe hypoxemia or unstable cardiac status (unless it is to secure the airway).

Q: About laryngomalacia, all are true except?

Curled epiglottis, flaccid arytenoids. **Laryngomalacia** is the most common congenital anomaly of the larynx and the leading cause of congenital stridor. It is characterized by an inward collapse of the supraglottic structures during inspiration. ### **Explanation of Options** * **Why Option A is the Correct Answer (The "Except"):** While the epiglottis is indeed curled (Omega-shaped), the primary pathology involves the **aryepiglottic folds**, which are characteristically short and flaccid, causing them to collapse inward. While the arytenoids may appear prominent or "fleshy," the classic description focuses on the shortening and flaccidity of the **aryepiglottic folds** rather than the arytenoids themselves in isolation. Therefore, Option A is the least accurate description compared to the standard clinical definition. * **Option B & C (True Statements):** These describe the classic pathophysiology. The supraglottic larynx is flaccid (C), and the epiglottis is typically elongated and curled upon itself (**Omega-shaped epiglottis**) with shortened, flaccid aryepiglottic folds (B). * **Option D (True Statement):** In approximately 90% of cases, the condition is self-limiting and resolves by 18–24 months of age. Therefore, **conservative management** (observation and reflux control) is the mainstay of treatment. ### **NEET-PG High-Yield Pearls** * **Clinical Presentation:** Inspiratory stridor that increases with crying, feeding, or lying supine; improves when prone. * **Diagnosis:** Flexible fiberoptic laryngoscopy (Gold Standard) showing inward collapse of supraglottic structures. * **Surgical Management:** Indicated only in severe cases (failure to thrive, cor pulmonale, sleep apnea). The procedure of choice is **Supraglottoplasty**. * **Associated Condition:** Gastroesophageal reflux disease (GERD) is frequently present and exacerbates symptoms.

Q: What is the most common cause of acute laryngotracheal bronchitis?

Parainfluenza virus. **Explanation:** **Acute Laryngotracheobronchitis (LTB)**, commonly known as **Croup**, is a viral infection characterized by inflammation and narrowing of the subglottic airway. 1. **Why Parainfluenza virus is correct:** The **Parainfluenza virus (Type 1 and 2)** is the most common causative agent, accounting for nearly 75% of all cases. It typically affects children between 6 months and 3 years of age. The virus causes subglottic edema, leading to the classic clinical triad of **barking cough, inspiratory stridor, and hoarseness.** 2. **Why other options are incorrect:** * **Haemophilus influenzae:** This is the primary cause of **Acute Epiglottitis**, not LTB. Epiglottitis is a medical emergency involving the supraglottic structures and is characterized by the "thumb sign" on X-ray. * **Influenza virus:** While it can cause respiratory infections and occasionally severe croup, it is less common than Parainfluenza. * **Coxsackievirus:** This is typically associated with Herpangina or Hand-Foot-and-Mouth disease, not primary laryngeal infections. **High-Yield Clinical Pearls for NEET-PG:** * **Radiological Sign:** The characteristic X-ray finding in Croup is the **"Steeple Sign"** (subglottic narrowing) on an AP view of the neck. * **Management:** Mild cases are managed with hydration and humidity. Severe cases require **nebulized adrenaline** (to reduce edema) and **corticosteroids** (Dexamethasone). * **Seasonality:** It most commonly occurs in late autumn and winter. * **Differential:** Always differentiate from Epiglottitis (high fever, drooling, sitting in tripod position) and Foreign Body Aspiration.

Question 1

What is the most common cause of stridor in children?

Accepted Answer

Laryngomalacia

Answer

Congenital laryngeal paralysis

Answer

Foreign body in larynx

Answer

Congenital laryngeal tumors

Question 2

Hoarseness of voice occurs early in which of the following conditions?

Accepted Answer

Glottic carcinoma

Answer

Subglottic carcinoma

Answer

Supraglottic carcinoma

Answer

None of the above

Question 3

What is the most common cause of unilateral left vocal cord palsy?

Accepted Answer

Trauma

Answer

Carcinoma of the thyroid

Answer

Carcinoma of the esophagus

Answer

Idiopathic

Question 4

Which procedure should precede microlaryngoscopy?

Accepted Answer

Laryngoendoscopy

Answer

Pharyngoscopy

Answer

Esophagoscopy

Answer

Rhinoscopy

Question 5

Turban epiglottitis is a clinical finding in which of the following conditions?

Accepted Answer

Tubercular laryngitis

Answer

Tubercular pharyngitis

Answer

Polypoid degeneration of vocal cord

Answer

Subglottic hemangioma

Question 6

The best way to diagnose laryngomalacia is:

Accepted Answer

Flexible fibreoptic laryngoscopy

Answer

Symptoms and signs of disease only

Answer

Soft tissue lateral view neck

Answer

Direct laryngoscopy under general anaesthesia

Question 7

What is the treatment of choice for T1N0M0 glottic carcinoma?

Accepted Answer

External beam radiotherapy

Answer

Surgery

Answer

Brachytherapy

Answer

Chemotherapy

Question 8

What is the advantage of flexible bronchoscopy?

Accepted Answer

All of the above

Answer

Can be performed in an awake patient

Answer

Allows examination of subsegmental bronchi

Answer

Can be used in patients with jaw and neck abnormalities

Question 9

About laryngomalacia, all are true except?

Accepted Answer

Curled epiglottis, flaccid arytenoids

Answer

Curled epiglottis, flaccid aryepiglottic fold

Answer

Flaccidity of the supraglottic larynx

Answer

Treatment is conservative

Question 10

What is the most common cause of acute laryngotracheal bronchitis?

Accepted Answer

Parainfluenza virus

Answer

Haemophilus influenzae

Answer

Influenza virus

Answer

Coxsackievirus

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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