Diseases of the Larynx Practice Questions

Q: Which of the following are of viral origin?

Vocal nodule. **Explanation** The question asks to identify which condition is **NOT** of viral origin (based on the provided answer key indicating Vocal Nodule as the correct choice). * **Vocal Nodule (Correct Answer):** This is a non-neoplastic inflammatory condition caused by **mechanical trauma** due to vocal abuse or misuse (e.g., screaming, singing). It is characterized by bilateral, symmetrical thickening at the junction of the anterior 1/3 and posterior 2/3 of the vocal cords. It has no viral etiology. * **Laryngeal Papilloma (Incorrect):** This is caused by the **Human Papillomavirus (HPV)**, specifically types 6 and 11. It is the most common benign neoplasm of the larynx in children (Juvenile Onset Recurrent Respiratory Papillomatosis). * **Nasopharyngeal Carcinoma (Incorrect):** This malignancy has a strong causal association with the **Epstein-Barr Virus (EBV)**, particularly the undifferentiated type (WHO Type 3). * **Laryngeal Web (Incorrect):** This is typically a **congenital** anomaly resulting from the failure of the laryngeal lumen to recanalize during the 10th week of gestation. While not viral, it is also not the primary "mechanical/inflammatory" condition usually contrasted with viral lesions in this context. **High-Yield Clinical Pearls for NEET-PG:** * **Vocal Nodule:** Also known as "Singer’s Nodule" or "Screamer’s Nodule." Treatment is primarily **voice therapy**; surgery is reserved for persistent cases. * **HPV 6 & 11:** Responsible for both Laryngeal Papillomatosis and Genital Warts (Condyloma Acuminata). * **EBV Markers:** IgA antibodies against Viral Capsid Antigen (VCA) are used for screening Nasopharyngeal Carcinoma. * **Laryngeal Web:** Most common site is the **glottis** (anterior commissure). Diagnosis is via direct laryngoscopy.

Q: A 4-year-old child presents with a history of hoarseness, croupy cough, and aphonia. The child has dyspnea with wheezing. What is the most probable diagnosis?

Laryngeal foreign body. ### **Explanation** The correct diagnosis is **Laryngeal Foreign Body (FB)**. **1. Why Laryngeal Foreign Body is correct:** The clinical triad of **hoarseness, croupy cough, and aphonia** is classic for a foreign body lodged in the larynx. Unlike bronchial foreign bodies (which typically present with unilateral wheezing), laryngeal FBs cause upper airway symptoms. The presence of **dyspnea and wheezing** (stridor/audible wheeze) indicates partial airway obstruction. In a 4-year-old, sudden onset of these symptoms without a prodromal fever strongly suggests an aspirated object. **2. Why the other options are incorrect:** * **Asthmatic bronchitis:** While it causes wheezing and dyspnea, it does not typically cause **aphonia** or a **croupy cough**. It is usually associated with a history of atopy and recurrent episodes. * **Bronchopneumonia:** This presents with high-grade fever, productive cough, and toxic appearance. It does not cause sudden aphonia or a localized croupy cough. * **Retropharyngeal abscess:** This presents with **dysphagia, drooling, and neck stiffness** (torticollis). While it can cause respiratory distress, the primary symptoms are related to swallowing rather than voice loss (aphonia). **3. NEET-PG High-Yield Pearls:** * **Site of Lodgement:** The most common site for aspirated foreign bodies is the **Right Main Bronchus** (due to it being wider, shorter, and more vertical). However, laryngeal FBs are the most life-threatening. * **Jackson’s Triad for Laryngeal FB:** Hoarseness, dyspnea, and croupy cough. * **Radiology:** Most aspirated FBs are **radiolucent** (e.g., peanuts); diagnosis often relies on clinical suspicion or indirect signs like obstructive emphysema. * **Management:** The gold standard for diagnosis and removal is **Rigid Bronchoscopy** under general anesthesia. For acute complete obstruction (choking), the **Heimlich maneuver** (or back blows/chest thrusts in infants) is indicated.

Q: In a child with suspected diagnosis of epiglottitis, what is your first line of treatment?

Secure an airway by intubation. **Explanation:** **Acute Epiglottitis** is a life-threatening medical emergency characterized by rapid inflammation of the epiglottis, most commonly caused by *Haemophilus influenzae* type B (Hib). **1. Why Option D is Correct:** In pediatric patients, the airway is anatomically narrow and prone to sudden, complete obstruction due to edema. The **primary goal** in management is to **secure the airway** immediately. This is best achieved via endotracheal intubation in a controlled environment (Operating Theater) with a surgical team ready for an emergency tracheostomy if needed. Clinical stability takes precedence over diagnostic confirmation. **2. Why Other Options are Incorrect:** * **Option A:** While a lateral neck X-ray showing the **"Thumb sign"** is classic, it should never delay airway management. Transporting an unstable child to the radiology suite can lead to fatal respiratory arrest. * **Option B:** While cultures and IV fluids are part of management, they are secondary. Attempting to start an IV line in a struggling child can trigger a laryngospasm. * **Option C:** Laryngoscopy (especially with a tongue depressor) in an un-intubated child is **strictly contraindicated** in the ER/ward setting, as it can precipitate immediate total airway obstruction. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** The "4 Ds"—**D**rooling, **D**yspnea, **D**ysphagia, and **D**istress. * **Positioning:** The child often assumes the **"Tripod position"** (leaning forward on hands) to maintain airway patency. * **X-ray Finding:** **Thumb sign** (swollen epiglottis) and **Vallecula sign** (obliteration of the vallecula). * **Management Rule:** "Never leave the child alone and never examine the throat unless you are ready to intubate."

Q: All are true regarding laryngomalacia except:

Poor prognosis. **Explanation:** Laryngomalacia is the **most common congenital anomaly of the larynx** and the most frequent cause of congenital stridor in infants. It is characterized by an inward collapse of the supraglottic structures (epiglottis, aryepiglottic folds) during inspiration due to abnormal flaccidity. **Why "Poor Prognosis" is the correct answer (the false statement):** Laryngomalacia generally has an **excellent prognosis**. In the vast majority of cases (approx. 90%), it is a self-limiting condition that resolves spontaneously by the age of 18–24 months as the laryngeal cartilage matures and hardens. Surgical intervention (Supraglottoplasty) is reserved only for severe cases involving failure to thrive or cor pulmonale. **Analysis of other options:** * **Most common congenital anomaly:** It accounts for nearly 60-70% of all congenital laryngeal problems. * **Stridor:** The hallmark clinical feature is **inspiratory stridor**, which typically appears within the first two weeks of life. * **Relieved in prone position:** The stridor characteristically worsens when the infant is supine, crying, or feeding, and is **relieved when the infant is placed in the prone position** or with the neck extended, as gravity helps pull the supraglottic structures forward. **Clinical Pearls for NEET-PG:** * **Omega-shaped epiglottis:** The classic endoscopic finding due to the folding of the epiglottis. * **Diagnosis:** Flexible fiberoptic laryngoscopy is the gold standard (shows inward collapse of aryepiglottic folds). * **Associated condition:** Gastroesophageal reflux (GERD) is frequently associated and can worsen the symptoms. * **Management:** Reassurance and observation are the primary treatments for mild to moderate cases.

Q: Thumb printing sign is seen in which of the following conditions?

Acute epiglottitis. ### Explanation **Correct Option: A. Acute epiglottitis** The **"Thumb sign"** (or thumbprinting sign) is a classic radiological finding seen on a **lateral soft tissue X-ray of the neck**. It occurs due to the severe inflammatory edema and swelling of the epiglottis, which causes it to lose its normal thin, leaf-like appearance and instead look like the rounded silhouette of a human thumb. * **Etiology:** Most commonly caused by *Haemophilus influenzae* type B (Hib). * **Clinical Presentation:** Characterized by the "4 Ds"—Drooling, Dysphagia, Dysphonia, and Distressed inspiratory efforts. Patients often adopt a "Tripod position" to maintain the airway. **Why the other options are incorrect:** * **B. Acute laryngotracheobronchitis (Croup):** This condition typically shows the **"Steeple sign"** (or Pencil-tip sign) on an **Anteroposterior (AP) X-ray**, caused by subglottic narrowing. * **C. Acute laryngitis:** This is usually a viral, self-limiting condition presenting with hoarseness. X-rays are generally normal and not used for diagnosis. * **D. Carcinoma of vocal cords:** This presents with chronic progressive hoarseness. While imaging (CT/MRI) is used for staging, it does not produce a "thumb sign." **High-Yield Clinical Pearls for NEET-PG:** * **Management Priority:** The first step is always **airway maintenance** (intubation or tracheostomy). **Never** examine the throat with a tongue depressor in a suspected case, as it can trigger fatal laryngospasm. * **Drug of Choice:** Intravenous Ceftriaxone. * **Omega Sign:** On direct laryngoscopy, the epiglottis appears swollen and "cherry red." * **Incidence:** Decreasing in children due to the Hib vaccine, but increasingly seen in adults.

Q: Structures removed in vertical partial laryngectomy are all except?

Epiglottis. **Explanation:** Vertical Partial Laryngectomy (VPL) is a conservative surgical procedure designed for early-stage glottic carcinomas (T1 and select T2). The primary goal is to remove the tumor while preserving the airway and voice, avoiding a permanent tracheostomy. **Why Epiglottis is the correct answer:** The epiglottis is a **supraglottic** structure. Vertical partial laryngectomy specifically targets the **glottic** compartment (the level of the vocal cords). Removal of the epiglottis is characteristic of a *Horizontal Partial Laryngectomy* (Supraglottic Laryngectomy), not a vertical one. In VPL, the incision is made vertically, sparing the supraglottic structures to maintain the protective function of the larynx during swallowing. **Analysis of incorrect options:** * **True cord (A):** The involved vocal cord is the primary structure removed in VPL to ensure oncological clearance of the glottic tumor. * **Thyroid cartilage (D):** The overlying ala of the thyroid cartilage on the affected side is removed to access the endolarynx and ensure a deep margin. * **Arytenoid (C):** Depending on the posterior extension of the tumor (e.g., in Extended VPL), the vocal process or the entire arytenoid cartilage on the involved side may be resected. **Clinical Pearls for NEET-PG:** * **Indications:** T1 glottic cancer involving the anterior commissure or T2 lesions with limited subglottic extension (<5mm). * **Contraindication:** Fixed vocal cord (T3) is a relative contraindication for standard VPL; it usually requires a Total Laryngectomy or Near-total Laryngectomy. * **Voice:** Post-operatively, a "pseudocord" forms from scar tissue, allowing for a functional but breathy voice. * **Key Distinction:** **Vertical** = Glottic tumors; **Horizontal** = Supraglottic tumors.

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

Total thyroidectomy. **Explanation:** **1. Why Total Thyroidectomy is Correct:** Iatrogenic injury during surgery is the most common cause of vocal cord palsy. Specifically, **Total Thyroidectomy** is the leading cause because of the close anatomical proximity of the **Recurrent Laryngeal Nerve (RLN)** to the inferior thyroid artery and the ligament of Berry. During the procedure, the nerve can be damaged via transection, clamping, or traction, leading to paralysis of the intrinsic muscles of the larynx (except the cricothyroid). **2. Analysis of Incorrect Options:** * **B. Bronchogenic Carcinoma:** This is the most common **malignant** cause of vocal cord palsy. It typically affects the left side because the left RLN loops under the arch of the aorta and can be compressed by hilar masses or mediastinal lymphadenopathy. * **C. Aneurysm of Aorta:** This causes **Ortner’s Syndrome** (cardiovocal syndrome). The dilated aortic arch stretches the left RLN. While a classic exam finding, it is statistically less common than surgical trauma. * **D. Tubercular Lymph Nodes:** These can cause palsy via apical pleurisy or direct compression by enlarged mediastinal nodes, but this is now a rare etiology compared to surgical and neoplastic causes. **3. NEET-PG High-Yield Pearls:** * **Most common nerve involved:** Left Recurrent Laryngeal Nerve (due to its longer intrathoracic course). * **Most common cause of Unilateral palsy:** Surgical trauma (Thyroidectomy). * **Most common cause of Bilateral palsy:** Thyroid surgery. * **Semon’s Law:** In progressive lesions, abductor fibers are injured first; thus, the cord initially moves to the midline (adducted position). * **Position of cord in RLN palsy:** Paramedian. * **Position of cord in Combined (RLN + SLN) palsy:** Cadaveric (intermediate).

Q: What is the symptom of a person with unilateral abductor paralysis of the vocal cords?

Transient hoarseness. In **unilateral abductor paralysis**, the affected vocal cord lies in the **median or paramedian position** because the adductors (lateral cricoarytenoid and interarytenoid) are still functional, while the abductor (posterior cricoarytenoid) is paralyzed. ### Why "Transient Hoarseness" is Correct: When one cord is paralyzed in the midline, the healthy vocal cord can still cross the midline to meet the paralyzed one. This **compensatory mechanism** allows for adequate glottic closure during phonation. Initially, the patient may experience mild hoarseness due to the sudden change in tension and position, but this is **transient** as the contralateral cord compensates quickly. Because the airway remains half-open, the respiratory function is usually unaffected. ### Explanation of Incorrect Options: * **A. Dyspnea on exertion:** This is typically absent because one vocal cord is in the midline and the other abducts normally, leaving a sufficient glottic gap for quiet and even mildly strenuous breathing. * **C. Husky voice:** A husky or breathy voice is characteristic of **unilateral adductor paralysis** (where the cord is stuck in the lateral/abducted position), leading to a large glottic gap and air wastage. * **D. Inspiratory stridor:** This is the hallmark of **bilateral abductor paralysis**, where both cords lie in the midline, severely narrowing the airway. ### NEET-PG Clinical Pearls: * **Most common cause:** Trauma (specifically Thyroid surgery injuring the Recurrent Laryngeal Nerve). * **Position of cords:** In unilateral RLN palsy, the cord is **paramedian** (Semon’s Law). * **Bilateral Abductor Paralysis:** This is a surgical emergency requiring tracheostomy because the airway is compromised, though the **voice remains remarkably good**. * **Unilateral Adductor Paralysis:** Rare as an isolated finding; usually seen in combined RLN and Superior Laryngeal Nerve lesions.

Q: Which of the following statements about Infraglottic carcinoma of the larynx is true?

It commonly spreads to mediastinal lymph nodes.. ### Explanation **Correct Answer: D. It commonly spreads to mediastinal lymph nodes.** **1. Why Option D is Correct:** The subglottis (infraglottic region) has a sparse lymphatic network compared to the supraglottis. However, when malignancy occurs here, the primary lymphatic drainage follows the pathway through the **cricothyroid membrane** to the **pre-laryngeal (Delphian)** and **pre-tracheal** nodes. From there, the drainage continues inferiorly into the **paratracheal** and **superior mediastinal lymph nodes**. This deep extension into the mediastinum is a characteristic feature of subglottic spread and often necessitates a mediastinal lymph node dissection during surgery. **2. Why Other Options are Incorrect:** * **Options A & B:** Glottic carcinoma (vocal cords) is the **most common** (approx. 60-65%), followed by Supraglottic carcinoma (approx. 30-35%). Subglottic (Infraglottic) carcinoma is the **rarest**, accounting for less than 5% of all laryngeal cancers. * **Option C:** Submental lymph nodes (Level Ia) primarily drain the floor of the mouth, tip of the tongue, and lower lip. They are not the primary drainage site for laryngeal structures. **3. High-Yield Clinical Pearls for NEET-PG:** * **Prognosis:** Subglottic cancers often present late with stridor or dyspnea because the region is clinically "silent" until the airway is compromised. They have a poorer prognosis compared to glottic cancers. * **Lymphatic Watershed:** The glottis (vocal cords) has virtually **no lymphatic drainage**, which is why early glottic cancer (T1) rarely metastasizes to the neck. * **Delphian Node:** The pre-laryngeal node is a classic "sentinel" node for subglottic and thyroid malignancies. Its involvement often indicates a higher risk of recurrence.

Q: What is the drug of choice in laryngeal stenosis?

Mitomycin C. **Explanation:** **Laryngeal stenosis** is characterized by the narrowing of the airway due to the formation of excessive fibrous scar tissue (fibroblasts). The primary challenge in surgical management is the high rate of recurrence due to postoperative scarring. **Why Mitomycin C is the Correct Answer:** Mitomycin C is an antineoplastic antibiotic derived from *Streptomyces caespitosus*. In the context of ENT, it is used **topically** as an anti-proliferative agent. It acts by inhibiting DNA synthesis and, most importantly, **inhibiting fibroblast proliferation and migration**. When applied to the site of a laryngeal web or stenosis after surgical dilation or excision, it significantly reduces collagen synthesis and prevents the formation of new scar tissue, thereby maintaining the patency of the airway. **Analysis of Incorrect Options:** * **A. Cyclophosphamide:** An alkylating agent primarily used in systemic chemotherapy or for autoimmune conditions like Wegener’s Granulomatosis (which can cause subglottic stenosis), but it is not the drug of choice for treating the stenosis itself. * **B. Doxorubicin & C. Adriamycin:** These are the same drug (Adriamycin is a brand name). It is an anthracycline chemotherapy agent used for systemic malignancies. It does not have a recognized topical role in preventing airway scarring. **Clinical Pearls for NEET-PG:** * **Application:** Mitomycin C is typically applied topically using a soaked cotton pledget (concentration: 0.4 mg/ml to 1 mg/ml) for 2–5 minutes. * **Other Uses in ENT:** It is also used to maintain patency in **Choanal Atresia** surgery and **Dacryocystorhinostomy (DCR)**. * **Most common site:** The subglottis is the most common site of laryngeal stenosis (Subglottic Stenosis), often secondary to prolonged intubation.

Question 1

Which of the following are of viral origin?

Accepted Answer

Vocal nodule

Answer

Laryngeal papilloma

Answer

Nasopharyngeal carcinoma

Answer

Laryngeal web

Question 2

A 4-year-old child presents with a history of hoarseness, croupy cough, and aphonia. The child has dyspnea with wheezing. What is the most probable diagnosis?

Accepted Answer

Laryngeal foreign body

Answer

Asthmatic bronchitis

Answer

Bronchopneumonia

Answer

Retropharyngeal abscess

Question 3

In a child with suspected diagnosis of epiglottitis, what is your first line of treatment?

Accepted Answer

Secure an airway by intubation

Answer

Order an X-ray of the soft tissue lateral view of the neck to establish the diagnosis

Answer

Take a throat swab and blood culture and start intravenous fluids

Answer

Perform a laryngoscopy

Question 4

All are true regarding laryngomalacia except:

Accepted Answer

Poor prognosis

Answer

Most common congenital anomaly of the larynx

Answer

Stridor

Answer

Gets relieved in prone position

Question 5

Thumb printing sign is seen in which of the following conditions?

Accepted Answer

Acute epiglottitis

Answer

Acute laryngotracheobronchitis

Answer

Acute laryngitis

Answer

Carcinoma of vocal cords

Question 6

Structures removed in vertical partial laryngectomy are all except?

Accepted Answer

Epiglottis

Answer

True cord

Answer

Arytenoid

Answer

Thyroid cartilage

Question 7

What is the most common cause of vocal cord palsy?

Accepted Answer

Total thyroidectomy

Answer

Bronchogenic carcinoma

Answer

Aneurysm of aorta

Answer

Tubercular lymph nodes

Question 8

What is the symptom of a person with unilateral abductor paralysis of the vocal cords?

Accepted Answer

Transient hoarseness

Answer

Dyspnea on exertion

Answer

Husky voice

Answer

Inspiratory stridor

Question 9

Which of the following statements about Infraglottic carcinoma of the larynx is true?

Accepted Answer

It commonly spreads to mediastinal lymph nodes.

Answer

It is the most common carcinoma of the larynx.

Answer

It is the second most common carcinoma of the larynx.

Answer

It commonly spreads to submental lymph nodes.

Question 10

What is the drug of choice in laryngeal stenosis?

Accepted Answer

Mitomycin C

Answer

Cyclophosphamide

Answer

Doxorubicin

Answer

Adriamycin

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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