Diseases of the Larynx Practice Questions

Q: Which of the following is NOT a common cause of stridor?

Atrophic laryngitis. **Explanation:** Stridor is a high-pitched, predominantly inspiratory sound produced by turbulent airflow through a partially obstructed upper airway (larynx or trachea). **Why Atrophic Laryngitis is the correct answer:** Atrophic laryngitis is a chronic condition characterized by the atrophy of the laryngeal mucosa and crust formation. While it causes hoarseness of voice and a dry cough, it **does not typically cause significant airway narrowing** or acute obstruction. Therefore, it is not a recognized cause of stridor. **Analysis of Incorrect Options:** * **Foreign body in larynx and trachea:** This is a common cause of **acute stridor** in toddlers. A lodged object creates mechanical obstruction, leading to sudden-onset respiratory distress and inspiratory or biphasic stridor. * **Laryngomalacia:** This is the **most common congenital cause** of stridor in infants. It occurs due to an inward collapse of supraglottic structures (like the epiglottis) during inspiration, resulting in a characteristic "crowing" sound that worsens when the infant is supine. * **Multiple papillomas of larynx:** Also known as Juvenile Recurrent Respiratory Papillomatosis (caused by HPV 6 and 11), these benign growths physically obstruct the glottic opening, leading to progressive hoarseness and stridor. **NEET-PG High-Yield Pearls:** * **Most common cause of inspiratory stridor in neonates:** Laryngomalacia. * **Most common cause of acute stridor (6 months – 3 years):** Laryngotracheobronchitis (Croup). * **Biphasic stridor** usually indicates a lesion at the **subglottic** or tracheal level. * **Expiratory stridor (wheeze)** usually indicates obstruction in the **lower airways** (bronchi).

Q: Laryngeal edema is a life-threatening situation seen in association with which of the following conditions?

Ludwig's angina. ### Explanation **Ludwig’s Angina** is a rapidly spreading, life-threatening cellulitis of the submandibular space (including sublingual and submaxillary spaces), usually of dental origin. The correct answer is **C** because the infection causes massive swelling of the floor of the mouth, pushing the tongue superiorly and posteriorly. This displacement, combined with the spread of edema to the epiglottis and supraglottic structures via the parapharyngeal space, leads to acute airway obstruction and **laryngeal edema**. **Analysis of Incorrect Options:** * **A. Cavernous Sinus Thrombosis:** This is a late complication of infections in the "danger area of the face." It presents with proptosis, chemosis, and cranial nerve palsies (III, IV, V1, V2, VI), but does not typically cause laryngeal edema. * **B. Infection of Pharyngeal Tonsils:** Acute tonsillitis or adenoiditis primarily causes odynophagia or nasal obstruction. While a peritonsillar abscess (Quinsy) can cause some trismus, it rarely leads to generalized laryngeal edema unless it spreads to the deep neck spaces. * **D. Cellulitis:** General skin cellulitis (unless specifically involving the submandibular space as in Ludwig's) does not involve the deep neck structures required to trigger laryngeal edema. **Clinical Pearls for NEET-PG:** * **Source:** 70-80% of Ludwig’s Angina cases arise from the **2nd and 3rd lower molars**. * **Clinical Sign:** "Woody" or "brawny" edema of the neck; the patient often presents with a "bull-neck" appearance and drooling. * **Management:** The priority is **airway maintenance** (often requiring tracheostomy if intubation fails). Antibiotics and surgical drainage are secondary. * **Key Space:** It is a **submandibular space** infection; it does not involve the subdiaphragmatic or retropharyngeal spaces primarily.

Q: Which of the following is NOT true regarding Reinke's edema?

There is asymmetrical swelling of the vocal cords.. **Reinke’s Edema** is a condition characterized by the accumulation of gelatinous fluid in the **subepithelial space (Reinke’s space)** of the vocal cords, located between the squamous epithelium and the vocal ligament. ### Why Option C is the Correct Answer (The False Statement) Reinke’s edema typically presents as **symmetrical, bilateral swelling** of the entire length of the membranous vocal cords. While the degree of swelling may vary slightly between sides, the hallmark of the disease is its diffuse, bilateral nature, often described as "baggy" or "polypoid" vocal cords. Therefore, stating that it is asymmetrical is incorrect. ### Analysis of Other Options * **Option A (Vocal Abuse):** This is **true**. The primary etiological factors are chronic irritation, most commonly due to **heavy smoking** and **vocal abuse** (voice strain). * **Option B (Subepithelial space):** This is **true**. Reinke’s space is a potential space with sparse lymphatic drainage, making it prone to fluid accumulation under chronic irritation. * **Option D (Vocal cord stripping):** This is **true**. While smoking cessation and voice therapy are initial steps, the definitive surgical treatment is **decortication** or "vocal cord stripping" (Micro-laryngeal surgery), where the epithelium is incised and the gelatinous fluid is aspirated/removed. ### NEET-PG High-Yield Pearls * **Clinical Presentation:** Characteristically seen in middle-aged women who smoke, presenting with a **low-pitched, "husky" voice**. * **Histopathology:** Shows edema, vascular congestion, and hyalinization of the stroma. * **Hirano’s Layers:** Reinke’s space corresponds to the **superficial layer of the lamina propria**. * **Management Tip:** Always rule out hypothyroidism, as it can present with similar vocal cord changes (Myxedema of the larynx).

Q: What is the most common cause of laryngeal stridor in a 60-year-old male?

Carcinoma of the larynx. **Explanation:** The correct answer is **Carcinoma of the larynx**. In an elderly male (60 years old), any new-onset laryngeal symptom—particularly stridor or persistent hoarseness—must be considered a malignancy until proven otherwise. Stridor indicates a significant narrowing of the airway (usually >50% obstruction). Squamous cell carcinoma is the most common laryngeal malignancy and typically presents in this age group, often associated with a history of smoking and alcohol consumption. **Analysis of Incorrect Options:** * **Nasopharyngeal Carcinoma:** While common in certain demographics, it typically presents with a neck mass (level II lymph nodes), nasal obstruction, or serous otitis media. It does not primarily cause laryngeal stridor unless there is massive inferior extension or cranial nerve palsy affecting the vocal cords. * **Acute Severe Asthma:** This presents with expiratory wheezing rather than inspiratory stridor. While it causes respiratory distress, the pathology is in the lower airways (bronchioles), not the larynx. * **Reinke’s Edema:** This involves fluid accumulation in the subepithelial space of the vocal cords. While it causes a "low-pitched, gravelly voice," it rarely progresses to the point of causing acute stridor unless the edema is massive and bilateral. **Clinical Pearls for NEET-PG:** * **Age-related Stridor:** In neonates, the most common cause is **Laryngomalacia**. In children, it is often **Croup (Laryngotracheobronchitis)** or foreign body aspiration. In elderly patients, **Malignancy** is the top differential. * **Stridor Types:** * *Inspiratory:* Supraglottic/Glottic lesion. * *Biphasic:* Subglottic lesion. * *Expiratory:* Tracheal/Bronchial lesion. * **Rule of Thumb:** Any patient with hoarseness for more than 3 weeks requires a mandatory indirect laryngoscopy (IDL) or fiberoptic laryngoscopy to rule out carcinoma.

Q: Cadaveric position of vocal cords is seen in which condition?

Bilateral recurrent and superior laryngeal nerve palsy. ### Explanation The position of the vocal cords is determined by the balance of intrinsic laryngeal muscles. The **cadaveric position** (neutral position) occurs when the vocal cords are approximately 3.5 mm from the midline, representing a state of total denervation. **1. Why Option A is Correct:** The vocal cords are controlled by two main nerves: the **Recurrent Laryngeal Nerve (RLN)**, which supplies all intrinsic muscles except the cricothyroid, and the **Superior Laryngeal Nerve (SLN)**, specifically its external branch, which supplies the cricothyroid (the primary tensor). * In **Bilateral RLN palsy**, the cords usually lie in the paramedian position because the cricothyroid muscles (supplied by the intact SLN) continue to adduct the cords. * When **both the RLN and SLN are paralyzed bilaterally**, the cricothyroid also loses function. This results in a total loss of muscle tone, causing the cords to fall into the **cadaveric position**. **2. Why Other Options are Incorrect:** * **Option B (Bilateral RLN palsy):** The cords are in the **paramedian position**. This is a surgical emergency as it causes severe airway obstruction (stridor), though the voice may remain relatively good. * **Option C & D (SLN palsy):** Isolated SLN palsy primarily affects the tension of the cords. It results in a wavy or "scalloped" appearance of the cord margin and a loss of high-pitched notes, but not a cadaveric position. **3. High-Yield Clinical Pearls for NEET-PG:** * **Median Position (0 mm):** Seen in phonation. * **Paramedian Position (1.5 mm):** Seen in isolated RLN palsy. * **Cadaveric Position (3.5 mm):** Seen in combined RLN + SLN palsy. * **Full Abduction (7 mm):** Seen during deep inspiration. * **Semon’s Law:** States that in progressive nerve lesions, the abductor fibers (posterior cricoarytenoid) are more susceptible and paralyzed earlier than adductor fibers.

Q: Which of the following is NOT a complication of tracheostomy?

Subglottic stenosis. **Explanation:** Tracheostomy complications are traditionally classified into immediate, intermediate, and late. Understanding the anatomical level of the procedure is key to identifying its complications. **Why Subglottic Stenosis is the Correct Answer:** Subglottic stenosis is typically a complication of **prolonged endotracheal intubation** or a **high tracheostomy** (where the incision involves the first tracheal ring or cricoid cartilage). In a standard tracheostomy, the incision is made between the 2nd and 4th tracheal rings. Since the subglottis (the area below the vocal cords and within the cricoid ring) is located **above** the standard tracheostomy site, a correctly performed procedure does not cause subglottic stenosis. Instead, the corresponding late complication of tracheostomy is **Tracheal Stenosis** (at the site of the stoma or cuff). **Analysis of Incorrect Options:** * **Surgical Emphysema:** An immediate complication caused by air escaping into the subcutaneous tissues, often due to tight skin suturing or excessive dissection of pretracheal fascia. * **Pneumothorax:** Occurs due to direct injury to the apical pleura (especially in children where the pleura is high) or due to air tracking through the mediastinum (pneumomediastinum) into the pleural space. * **Carotid Artery Injury:** Though rare, the carotid artery or the innominate artery can be injured during the procedure, especially in cases of aberrant anatomy or "low" tracheostomies. **High-Yield Clinical Pearls for NEET-PG:** * **Most common immediate complication:** Hemorrhage. * **Most common late complication:** Tracheal stenosis. * **Most common cause of death in tracheostomy:** Displacement of the tube or accidental decannulation. * **Tracheoinnominate Artery Fistula:** A rare but fatal late complication usually occurring due to a low-placed stoma (below the 4th ring).

Q: What is the most common site in the larynx for sarcoidosis?

Epiglottis. **Explanation:** Laryngeal sarcoidosis is a rare manifestation of systemic sarcoidosis, occurring in approximately 1–5% of cases. It is characterized by the formation of non-caseating granulomas in the laryngeal tissues. **Why Epiglottis is the Correct Answer:** The disease has a strong predilection for the **supraglottic larynx** because of its rich lymphatic network. Within the supraglottis, the **epiglottis** is the most frequently involved site. On examination, it typically appears thickened, pale, and edematous (often described as "turban-shaped"), which can lead to symptoms like globus sensation, dysphagia, or airway obstruction. **Analysis of Incorrect Options:** * **Vocal Cords (Glottis):** Involvement of the true vocal cords is extremely rare. Sarcoidosis primarily affects the "loose" mucosa of the supraglottis rather than the tightly bound squamous epithelium of the vocal folds. * **Cartilage:** While sarcoidosis can affect various connective tissues, it is primarily a mucosal and submucosal disease in the larynx. It does not typically originate in or primarily target the laryngeal cartilages. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Epiglottis (Supraglottis). * **Classic Appearance:** Pale, edematous, "turban-like" epiglottis. * **Presenting Symptom:** Most patients are asymptomatic, but the most common symptom is hoarseness or inspiratory stridor if the airway is narrowed. * **Diagnosis:** Definitive diagnosis requires a biopsy showing **non-caseating granulomas** and exclusion of other causes like tuberculosis (which usually involves the posterior larynx). * **Treatment:** Systemic or intralesional corticosteroids are the mainstay of management.

Question 1

Which of the following is NOT a common cause of stridor?

Accepted Answer

Atrophic laryngitis

Answer

Foreign body in larynx and trachea

Answer

Laryngomalacia

Answer

Multiple papillomas of larynx

Question 2

Laryngeal edema is a life-threatening situation seen in association with which of the following conditions?

Accepted Answer

Ludwig's angina

Answer

Cavernous sinus thrombosis

Answer

Infection of pharyngeal tonsils

Answer

Cellulitis

Question 3

Which of the following is NOT true regarding Reinke's edema?

Accepted Answer

There is asymmetrical swelling of the vocal cords.

Answer

It is usually caused by vocal abuse.

Answer

There is a collection of edema fluid in the subepithelial space.

Answer

Vocal cord stripping is the treatment.

Question 4

What is the most common cause of laryngeal stridor in a 60-year-old male?

Accepted Answer

Carcinoma of the larynx

Answer

Nasopharyngeal carcinoma

Answer

Acute severe asthma

Answer

Reinke's edema

Question 5

Cadaveric position of vocal cords is seen in which condition?

Accepted Answer

Bilateral recurrent and superior laryngeal nerve palsy

Answer

Bilateral recurrent laryngeal nerve palsy

Answer

Unilateral superior laryngeal nerve palsy

Answer

Bilateral superior laryngeal nerve palsy

Question 6

Which of the following are indications for tracheostomy?

Accepted Answer

Flail chest, Head injury, Tetanus, Foreign body

Answer

Head injury, Tetanus, Cardiac tamponade, Foreign body

Answer

Flail chest, Head injury, Tetanus, Cardiac tamponade

Answer

Flail chest, Head injury, Cardiac tamponade, Foreign body

Question 7

Which of the following is NOT a complication of tracheostomy?

Accepted Answer

Subglottic stenosis

Answer

Surgical emphysema

Answer

Pneumothorax

Answer

Carotid artery injury

Question 8

Which laryngeal condition can present with hoarseness and stridor?

Accepted Answer

Neither unilateral nor bilateral vocal cord abductor paralysis

Answer

Unilateral vocal cord abductor paralysis

Answer

Bilateral vocal cord abductor paralysis

Answer

Both unilateral and bilateral vocal cord abductor paralysis

Question 9

What is the most common site in the larynx for sarcoidosis?

Accepted Answer

Epiglottis

Answer

Vocal cord

Answer

Cartilage

Answer

None of the above

Question 10

What is the gold standard treatment for intractable aspiration in a patient with an incompetent larynx due to complete laryngeal paralysis?

Accepted Answer

Tracheal division and permanent tracheostoma

Answer

Type I Thyroplasty

Answer

Tracheostomy

Answer

Feeding jejunostomy

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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