Diseases of the Larynx Practice Questions

Q: Regarding Juvenile laryngeal papillomatosis, which of the following statements is false?

HPV 18 is the causative agent.. ### Explanation **Juvenile Laryngeal Papillomatosis (JLP)**, also known as Recurrent Respiratory Papillomatosis (RRP), is the most common benign neoplasm of the larynx in children. **1. Why Option D is the Correct (False) Statement:** The primary causative agents for JLP are **HPV types 6 and 11** [1]. These are "low-risk" genotypes. In contrast, **HPV 16 and 18** are "high-risk" genotypes associated with cervical cancer and oropharyngeal squamous cell carcinoma, but they are **not** the typical cause of juvenile laryngeal papillomas. **2. Analysis of Other Options:** * **Option A (Recurrent):** True. The hallmark of this disease is its aggressive tendency to recur after surgical excision, often requiring multiple procedures (hence the name "Recurrent Respiratory Papillomatosis") [2]. * **Option B (Interferon):** True. While CO2 laser excision or microdebrider excision is the gold standard, adjuvant therapies like **Interferon-alpha**, Cidofovir, and Indole-3-carbinol are used in severe, rapidly recurring cases to slow down the growth [1]. * **Option C (Premalignant):** True. Although rare (less than 1-3%), these benign lesions can undergo malignant transformation into squamous cell carcinoma, especially if there is a history of smoking or prior radiation therapy [2]. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mode of Transmission:** Usually occurs during childbirth via an infected birth canal (maternal HPV 6/11) [2]. * **Triad of Symptoms:** Hoarseness (most common), stridor, and dyspnea [2]. * **Most Common Site:** True vocal cords. * **Histopathology:** Shows finger-like projections of non-keratinized stratified squamous epithelium with a central vascular core. **Koilocytes** (vacuolated cells) are a characteristic finding. * **Management Goal:** To maintain a patent airway and preserve voice quality, not necessarily "cure," due to the high recurrence rate [2].

Q: In type 4 thyroplasty, what happens to the vocal cord?

Lengthened. **Explanation:** Thyroplasty, as classified by **Isshiki**, refers to laryngeal framework surgeries designed to alter the position or tension of the vocal cords to improve voice quality. **Why Option C is Correct:** **Type 4 Thyroplasty (Cricothyroid Approximation)** is a **tension-increasing** procedure. It involves approximating the thyroid cartilage to the cricoid cartilage using sutures, mimicking the action of the cricothyroid muscle. This maneuver increases the distance between the anterior commissure and the arytenoids, thereby **lengthening** and tensing the vocal cords. It is clinically used to **raise the vocal pitch**, most commonly in cases of androphonia (high-pitched female voice) or for gender-affirming voice surgery (trans-women). **Analysis of Incorrect Options:** * **Option A (Medially displaced):** This occurs in **Type 1 Thyroplasty**, used for unilateral vocal cord palsy to improve glottic closure. * **Option B (Laterally displaced):** This occurs in **Type 2 Thyroplasty**, used to widen the glottis in conditions like adductor spasmodic dysphonia. * **Option D (Shortened):** This occurs in **Type 3 Thyroplasty (Relaxation Thyroplasty)**, where a vertical strip of cartilage is removed to reduce tension and **lower the pitch** (used in puberphonia). **High-Yield Clinical Pearls for NEET-PG:** * **Type 1:** Medialization (for Paralysis/Atrophy) – *Most common.* * **Type 2:** Lateralization (for Spasmodic Dysphonia). * **Type 3:** Relaxation/Shortening (to Lower Pitch). * **Type 4:** Stretching/Lengthening (to Raise Pitch). * **Mnemonic:** **M**edial, **L**ateral, **R**elax, **S**tretch (**M-L-R-S** for Types 1-4).

Q: What is the most common indication for tracheostomy?

Foreign body aspiration. **Explanation:** Tracheostomy is a surgical procedure that creates an opening in the anterior wall of the trachea to bypass an upper airway obstruction [1]. **Why Foreign Body Aspiration is Correct:** In the context of emergency clinical practice and competitive exams like NEET-PG, **Foreign Body (FB) aspiration** is considered the most common indication for an emergency tracheostomy [1]. When a foreign body becomes impacted in the larynx or subglottis, it causes acute, life-threatening airway obstruction. If the object cannot be removed via Heimlich maneuver or direct laryngoscopy, a tracheostomy is performed to establish a secure airway and prevent asphyxiation. **Analysis of Incorrect Options:** * **Laryngeal Diphtheria:** While a classic cause of airway obstruction (due to pseudomembrane formation), its incidence has drastically decreased due to widespread immunization (DPT/Pentavalent vaccine) [1]. * **Carcinoma:** Laryngeal or hypopharyngeal carcinoma is a common cause of *elective* or progressive airway obstruction, but it ranks below acute emergencies like foreign bodies in overall frequency for urgent intervention [1]. * **Asthma:** This is a disease of the lower airways (bronchospasm). Tracheostomy is ineffective because the obstruction is distal to the tracheal opening; management involves bronchodilators and steroids. **Clinical Pearls for NEET-PG:** * **Most common indication (Overall):** Respiratory failure requiring prolonged mechanical ventilation (to prevent subglottic stenosis from endotracheal tubes). * **Most common indication (Emergency):** Upper airway obstruction (e.g., Foreign body, trauma, or acute epiglottitis) [1]. * **Level of Tracheostomy:** Usually performed at the level of the **2nd and 3rd tracheal rings**. * **Most common immediate complication:** Hemorrhage. * **Most common late complication:** Tracheal stenosis.

Q: In direct laryngoscopy, which of the following structures cannot be visualized?

Cricothyroid membrane. ### Explanation **1. Why the Correct Answer is Right:** Direct Laryngoscopy (DL) is a procedure used to visualize the interior of the larynx and the hypopharynx. During DL, the laryngoscope is passed through the mouth to provide a direct line of sight to the **endolaryngeal structures**. The **Cricothyroid membrane** is an **extralaryngeal** structure located on the external surface of the neck, between the thyroid and cricoid cartilages. Because it is part of the external framework and lies deep to the skin and prelaryngeal muscles, it cannot be seen from the mucosal/luminal side during laryngoscopy. It is typically accessed via the skin during emergency cricothyrotomy. **2. Analysis of Incorrect Options:** * **Lingual surface of the epiglottis:** This is the anterior surface of the epiglottis facing the tongue. It is easily visualized as the laryngoscope blade is advanced into the vallecula (Macintosh blade) or used to depress the epiglottis (Miller blade). * **Arytenoids:** These paired cartilages form the posterior boundary of the glottis. They are primary landmarks used to identify the laryngeal inlet during intubation and DL. * **Pyriform fossa:** These are mucosal recesses located on either side of the laryngeal inlet within the hypopharynx. They are routinely inspected during DL to rule out hidden malignancies or foreign bodies. **3. Clinical Pearls for NEET-PG:** * **Positioning:** For optimal visualization during DL, the "Sniffing Position" is used (Flexion of the lower cervical spine and Extension of the atlanto-occipital joint). * **Indications:** DL is used for biopsies, removal of foreign bodies, and assessing the extent of laryngeal tumors (T-staging). * **Blind Spots:** While DL provides a great view of the glottis, the **subglottis** and the **ventricle** are considered "difficult zones" to visualize completely without the aid of angled telescopes or fiberoptic endoscopes.

Q: A palpatory thud, an audible snap, is observed in which of the following conditions?

Tracheal foreign body. **Explanation:** The classic triad of **Audible Slap, Palpatory Thud, and Asthmatoid Wheeze** is pathognomonic for a **Tracheal Foreign Body**. 1. **Why Tracheal Foreign Body is correct:** * **Audible Slap:** When the patient coughs or breathes forcefully, the foreign body is propelled upward and strikes the undersurface of the vocal cords. This produces a distinct slapping sound heard at the mouth. * **Palpatory Thud:** This is the tactile equivalent of the slap. If the examiner places a finger on the trachea (cricothyroid membrane) during coughing, they can feel the impact of the foreign body hitting the subglottis. * **Asthmatoid Wheeze:** Produced by air bypassing the obstruction in the trachea; it is heard best at the mouth with the patient's mouth open. 2. **Why other options are incorrect:** * **Bronchial Foreign Body:** These typically present with unilateral decreased breath sounds, localized wheezing, or obstructive emphysema/atelectasis. Since the object is lodged deeper in a smaller airway, it cannot move freely enough to strike the vocal cords. * **Laryngeal Foreign Body:** These present with acute respiratory distress, hoarseness, or aphonia. The object is usually wedged firmly, preventing the "bouncing" motion required for a thud or slap. * **Foreign Body in the Ear:** Presents with earache, deafness, or irritation; it has no correlation with respiratory sounds or tracheal palpation. **Clinical Pearls for NEET-PG:** * **Most common site** for inhaled foreign bodies: **Right main bronchus** (due to it being wider, shorter, and more vertical). * **Vegetable foreign bodies** (e.g., peanuts) are most dangerous as they cause **vegetal bronchitis** due to the release of fatty acids. * **Gold Standard Investigation:** Rigid Bronchoscopy (both diagnostic and therapeutic).

Q: What is the most common cause of chronic laryngeal stenosis?

Trauma. **Explanation:** **Trauma** is the most common cause of chronic laryngeal stenosis. In modern clinical practice, the most frequent subtype is **iatrogenic trauma**, specifically prolonged endotracheal intubation. High-pressure cuffs or oversized tubes cause ischemic necrosis of the laryngeal mucosa, leading to fibrosis and cicatricial narrowing. External laryngeal trauma (e.g., "clothesline" injuries or RTA) is the second most common traumatic cause. **Analysis of Options:** * **Tuberculosis (B):** While TB can cause laryngeal scarring (traditionally affecting the posterior commissure), it is a much rarer cause of stenosis today compared to intubation-related injury. * **Wegener’s Granulomatosis (C):** Now known as Granulomatosis with Polyangiitis (GPA), it typically causes **subglottic stenosis**. While a classic board-exam association, it is statistically rare compared to trauma. * **Tumor (D):** Laryngeal malignancies (like Squamous Cell Carcinoma) cause airway obstruction primarily through mass effect or vocal cord fixation rather than "stenosis" (which refers to a circumferential or cicatricial narrowing of the lumen). **High-Yield Pearls for NEET-PG:** 1. **Most common site of post-intubation stenosis:** Subglottis (the narrowest part of the adult airway and the only complete cartilaginous ring—the cricoid). 2. **Cotton-Myer Classification:** Used to grade the severity of subglottic stenosis based on the percentage of luminal narrowing. 3. **Management:** Grade I/II often respond to endoscopic dilation or laser excision; Grade III/IV usually require surgical reconstruction (e.g., Laryngotracheal Reconstruction or Cricotracheal Resection). 4. **Congenital Stenosis:** If the question specifies *congenital* causes, the most common is a malformed cricoid cartilage.

Q: What is the earliest sign of tuberculosis of the vocal cords?

Hyperemia of the free margin. ### Explanation Laryngeal tuberculosis is almost always secondary to pulmonary tuberculosis, occurring due to the expectoration of infected sputum. **1. Why "Hyperemia of the free margin" is correct:** The earliest pathological change in laryngeal TB is congestion. Specifically, **hyperemia (redness) of the free margins of the vocal cords** is the first clinical sign visible on laryngoscopy. This represents the initial inflammatory response before structural destruction or granulation tissue forms. **2. Analysis of Incorrect Options:** * **A. Mouse nibbled appearance:** This is a classic description of laryngeal TB, but it is a **later stage**. It occurs when multiple small ulcers coalesce along the edge of the vocal cords, giving them a jagged, "eaten-away" look. * **C. Turban epiglottis:** This refers to the marked edema and thickening of the epiglottis, making it look like a turban. This is a characteristic feature of **advanced** laryngeal TB, not the earliest sign. * **D. Ulceration of vocal cord:** Ulceration follows the initial hyperemic stage. These ulcers are typically shallow, pale, and exquisitely painful. **3. Clinical Pearls for NEET-PG:** * **Most common site:** Traditionally the **posterior commissure** (interarytenoid area), though recent trends show increasing involvement of the anterior larynx. * **Cardinal Symptom:** **Odynophagia** (painful swallowing) is often disproportionately severe compared to the physical findings. * **Hoarseness:** The most common presenting complaint. * **Diagnosis:** Gold standard is a biopsy (to rule out malignancy) and sputum for AFB/CBNAAT. * **Treatment:** Standard Anti-Tubercular Therapy (ATT). The laryngeal lesions usually heal rapidly once systemic treatment begins.

Question 1

A 10-year-old boy developed hoarseness of voice following an attack of diphtheria. No other significant cranial nerves or vocal cords are paralyzed. What is the treatment of choice?

Accepted Answer

Wait for spontaneous recovery

Answer

Get foam injection of right vocal cord

Answer

Fat injection of right vocal cord

Answer

Thyroplasty Type 1

Question 2

Regarding Juvenile laryngeal papillomatosis, which of the following statements is false?

Accepted Answer

HPV 18 is the causative agent.

Answer

It is recurrent.

Answer

Interferon is used in its treatment.

Answer

It is premalignant.

Question 3

A 26-year-old female presented with gradually increasing respiratory distress over 4 days. She has a history of hospitalization and mechanical ventilation with orotracheal intubation for 2 weeks. She is now diagnosed with severe tracheal stenosis. What would be the next line of management?

Accepted Answer

Tracheal resection and end-to-end anastomosis

Answer

Laser excision and stent insertion

Answer

Steroids

Answer

Tracheal dilatation

Question 4

In type 4 thyroplasty, what happens to the vocal cord?

Accepted Answer

Lengthened

Answer

Medially displaced

Answer

Laterally displaced

Answer

Shortened

Question 5

What is the most common indication for tracheostomy?

Accepted Answer

Foreign body aspiration

Answer

Laryngeal diphtheria

Answer

Carcinoma

Answer

Asthma

Question 6

In direct laryngoscopy, which of the following structures cannot be visualized?

Accepted Answer

Cricothyroid membrane

Answer

Lingual surface of the epiglottis

Answer

Arytenoids

Answer

Pyriform fossa

Question 7

A palpatory thud, an audible snap, is observed in which of the following conditions?

Accepted Answer

Tracheal foreign body

Answer

Bronchial foreign body

Answer

Laryngeal foreign body

Answer

Foreign body in the ear

Question 8

What is the most common cause of chronic laryngeal stenosis?

Accepted Answer

Trauma

Answer

Tuberculosis

Answer

Wegener's granulomatosis

Answer

Tumor

Question 9

A 10-year-old boy developed hoarseness of voice following an attack of diphtheria. On examination, his right vocal cord was paralysed. What is the initial recommended management for a paralysed vocal cord in this scenario?

Accepted Answer

Observation for spontaneous recovery of the vocal cord

Answer

Injection of gel foam into the right vocal cord

Answer

Fat injection into the right vocal cord

Answer

Thyroplasty type I

Question 10

What is the earliest sign of tuberculosis of the vocal cords?

Accepted Answer

Hyperemia of the free margin

Answer

Mouse nibbled appearance

Answer

Turban epiglotitis

Answer

Ulceration of vocal cord

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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