Diseases of the Larynx Practice Questions

Q: A 3-year-old male child presents with multiple laryngeal papillomas, hoarse voice, and slight airway distress. The papillomas involve the glottis. What is the best treatment?

Microlaryngoscopy and excision. **Explanation:** The clinical presentation is classic for **Juvenile Onset Recurrent Respiratory Papillomatosis (JORRP)**, most commonly caused by **HPV types 6 and 11**. **Why Microlaryngoscopy and Excision is correct:** The primary goal of management in JORRP is to maintain a patent airway and improve voice quality while minimizing damage to the underlying vocal fold tissues. **Microlaryngoscopic surgery** (using CO2 laser or microdebrider) is the **gold standard treatment**. It allows for precise removal of the papillomatous lesions. It is important to note that surgery is palliative, not curative, as the virus remains latent in the surrounding mucosa, often requiring multiple procedures. **Why other options are incorrect:** * **Tracheostomy:** This is avoided as much as possible because it can lead to **stomal seeding**, where the papillomas spread further down into the trachea and bronchi, significantly worsening the prognosis. * **Steroids:** These have no role in treating the viral etiology of papillomas and do not provide definitive airway clearance. * **Interferon therapy:** This is an adjuvant therapy used only in aggressive, refractory cases (more than 12 surgeries/year or rapid regrowth). It is not the first-line treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** HPV 6 and 11 (acquired during birth via the maternal birth canal). * **Most common site:** True vocal cords (Glottis). * **Triad of JORRP:** Hoarseness, stridor, and respiratory distress. * **Adjuvant therapies:** Cidofovir (intralesional), Bevacizumab (Avastin), and Indole-3-carbinol. * **Prevention:** Quadrivalent/Nonavalent HPV vaccine.

Q: All of the following are true about pachydermia laryngitis except?

Premalignant condition. **Pachydermia Laryngitis** is a specific form of chronic hypertrophic laryngitis characterized by the thickening of the epithelium in the posterior part of the larynx. ### **Explanation of Options** * **Why Option B is Correct (The False Statement):** Pachydermia laryngitis is **not a premalignant condition**. Unlike leukoplakia or erythroplakia of the larynx, which carry a risk of malignant transformation into squamous cell carcinoma, pachydermia is a benign reactive process. It is typically caused by chronic irritation from gastroesophageal reflux (GERD), smoking, or alcohol. * **Option A (Hoarseness):** This is the most common presenting symptom. The structural changes and thickening of the mucosa interfere with normal vocal cord vibration and glottic closure. * **Option C (Posterior Larynx):** This is a hallmark feature. The condition characteristically involves the **interarytenoid space** and the posterior third of the vocal cords (vocal processes). This area is most susceptible to irritation from gastric acid reflux. * **Option D (Histopathology):** Biopsy typically reveals **acanthosis** (thickening of the stratum spinosum) and **hyperkeratosis** (thickening of the stratum corneum). There is no cellular atypia or dysplasia, which reinforces its benign nature. ### **High-Yield Clinical Pearls for NEET-PG** * **Appearance:** On laryngoscopy, it often presents as a "heaped up" grayish-white or reddish mass in the interarytenoid area, sometimes showing a **"cup and saucer"** appearance (a contact ulcer on one side with a granuloma on the other). * **Treatment:** Management is conservative, focusing on voice rest and aggressive treatment of the underlying cause (e.g., Proton Pump Inhibitors for GERD and cessation of smoking). * **Differential Diagnosis:** Must be differentiated from **Laryngeal Tuberculosis**, which also involves the posterior larynx but presents with "mouse-nibbled" ulcers and systemic symptoms.

Q: What is the most common mode of treatment for laryngomalacia?

Reassurance. **Explanation:** **Laryngomalacia** is the most common congenital anomaly of the larynx and the most frequent cause of stridor in infants. It is characterized by an inward collapse of supraglottic structures (epiglottis, arytenoids) during inspiration. **Why Reassurance is the correct answer:** The vast majority of cases (approximately **90%**) are mild to moderate and follow a self-limiting course. Stridor typically appears at 2 weeks of age, peaks at 6–9 months, and **spontaneously resolves** by 18–24 months as the laryngeal cartilage matures and the airway widens. Therefore, the primary management strategy is parental reassurance and monitoring of growth. **Analysis of Incorrect Options:** * **Medical management (B):** While often used to treat comorbid Gastroesophageal Reflux Disease (GERD) which can exacerbate symptoms, it is not the primary treatment for the structural collapse itself. * **Surgical intervention (C):** Reserved for only **10% of cases** (Severe Laryngomalacia) presenting with "danger signs" such as failure to thrive, cor pulmonale, or life-threatening apnea. The surgery of choice is **Supraglottoplasty**. * **Observation (D):** While clinically similar to reassurance, "Reassurance" is the preferred terminology in exams to emphasize the benign, self-resolving nature of the condition to the caregivers. **High-Yield Clinical Pearls for NEET-PG:** * **Stridor characteristics:** Inspiratory, high-pitched, worsens when supine or crying, improves when prone. * **Omega-shaped epiglottis:** The classic endoscopic finding (due to short aryepiglottic folds). * **Diagnosis:** Confirmed by **Flexible Fiberoptic Laryngoscopy** in an awake, spontaneously breathing infant. * **Synchronous lesions:** 10-15% of patients may have a second airway lesion (e.g., subglottic stenosis).

Q: A middle-aged male presents with a 2-year history of hoarseness of voice. He has a 30-year smoking history. Examination reveals a reddish area of mucosal irregularity overlying a portion of both vocal cords. Which of the following management options would NOT be indicated?

Bilateral cordectomy. **Explanation:** The clinical presentation of chronic hoarseness in a long-term smoker with "reddish mucosal irregularity" (erythroplakia/leukoplakia) strongly suggests **Chronic Hypertrophic Laryngitis** or **Vocal Cord Dysplasia**, which are premalignant conditions. **Why Bilateral Cordectomy is NOT indicated:** A cordectomy (excision of the vocal cord) is a radical surgical procedure used for localized invasive carcinoma (T1a glottic cancer). Performing a **bilateral** cordectomy for a suspected premalignant lesion is contraindicated because: 1. It is overly aggressive for a condition that has not yet been histologically confirmed as invasive cancer. 2. It results in a devastating loss of voice and a high risk of laryngeal stenosis/airway compromise. **Analysis of other options:** * **Cessation of smoking:** This is the most critical first step in management to prevent further epithelial irritation and progression to malignancy. * **Microlaryngeal surgery (MLS) for biopsy:** This is the **gold standard** for diagnosis. Any suspicious mucosal irregularity must be biopsied to rule out Squamous Cell Carcinoma (SCC). * **Regular follow-up:** These patients require lifelong surveillance due to the high risk of malignant transformation in the dysplastic epithelium. **NEET-PG High-Yield Pearls:** * **Leukoplakia** (white patch) and **Erythroplakia** (red patch) are clinical terms, not histological diagnoses. * **Keratosis Pharyngeus** involves the tonsils/pharynx, whereas **Laryngeal Keratosis** is a precursor to glottic SCC. * The management ladder for laryngeal dysplasia: Smoking cessation → MLS with excisional biopsy (stripping) → Close follow-up. Radical surgery is reserved for confirmed invasive malignancy.

Q: Which of the following can be produced by reflux laryngitis?

Subglottic stenosis. **Explanation:** **Reflux Laryngitis** (Laryngopharyngeal Reflux - LPR) occurs when gastric contents, including acid and pepsin, backflow into the larynx. Unlike the esophagus, the laryngeal mucosa lacks protective mechanisms against acid, leading to chronic inflammation and tissue damage. **Why Subglottic Stenosis is the correct answer:** Chronic exposure to gastric acid causes persistent mucosal irritation, ulceration, and subsequent granulation tissue formation. In the subglottic region—the narrowest part of the upper airway—this inflammatory process leads to **fibrosis and scarring**, which can result in acquired **Subglottic Stenosis**. LPR is considered a significant co-factor in the failure of surgical repairs for stenosis and is a known etiologic factor in idiopathic cases. **Analysis of Incorrect Options:** * **B. Carcinoma of the larynx:** While chronic irritation is a risk factor, LPR is primarily associated with benign inflammatory changes (like contact granulomas). Tobacco and Alcohol remain the primary definitive precursors for laryngeal SCC. * **C. Cord fixation:** Reflux can cause vocal cord edema (Reinke’s edema) or granulomas, but it does not typically cause true cricoarytenoid joint ankylosis or nerve paralysis required for "fixation." * **D. Acute supraglottitis:** This is an acute bacterial infection (typically *H. influenzae*) characterized by rapid onset and "cherry red" epiglottis, not a chronic inflammatory condition like reflux. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of LPR:** Posterior commissure (Interarytenoid pachyderma). * **Common findings:** Contact ulcers/granulomas, pseudosulcus vocalis, and subglottic stenosis. * **Diagnosis:** Gold standard is **24-hour double-probe pH monitoring**. * **Treatment:** Lifestyle modification and aggressive Proton Pump Inhibitor (PPI) therapy (usually twice daily for 3–6 months).

Q: Which of the following is NOT true about supraglottic laryngeal carcinoma?

It is the most common site for carcinoma of the larynx.. **Explanation:** **1. Why Option A is the correct answer (The False Statement):** In the context of laryngeal carcinoma, the **glottis (vocal cords)** is the most common site, accounting for approximately 60-65% of cases. Supraglottic carcinoma is the second most common (30-35%), while subglottic carcinoma is the rarest (<5%). Therefore, stating that the supraglottis is the most common site is factually incorrect. **2. Analysis of other options:** * **Option B:** The supraglottis has a rich lymphatic network. Tumors here frequently metastasize bilaterally, primarily involving the **Level II (upper jugular)** and **Level III (middle jugular)** lymph nodes. * **Option C:** Unlike glottic cancer (which presents early with hoarseness), supraglottic cancer is often "silent" in its early stages. By the time symptoms appear, the disease is often advanced, and a **palpable neck mass** (due to nodal metastasis) is frequently the first clinical sign. * **Option D:** Early-stage supraglottic cancer (T1 and T2) can be treated with high success rates using either **External Beam Radiotherapy (EBRT)** or organ-preserving surgeries (like CO2 laser supraglottic laryngectomy), as both offer similar local control. **Clinical Pearls for NEET-PG:** * **Glottic Cancer:** Most common; presents early with hoarseness; best prognosis due to sparse lymphatics (rare nodal spread). * **Supraglottic Cancer:** Rich lymphatics; high incidence of bilateral nodal metastasis; presents late with throat pain, dysphagia, or a neck mass. * **Subglottic Cancer:** Often presents with stridor; carries the worst prognosis as it is usually diagnosed at an advanced stage.

Q: What is the drug of choice for the treatment of epiglottitis?

Ceftriaxone. **Explanation:** Acute Epiglottitis is a life-threatening medical emergency characterized by rapid inflammation of the epiglottis. While the incidence has decreased due to the Hib vaccine, the most common causative organism remains *Haemophilus influenzae* type b (Hib), followed by *Streptococcus pneumoniae* and *Staphylococcus aureus*. **Why Ceftriaxone is the Correct Choice:** Third-generation cephalosporins, specifically **Ceftriaxone**, are the drug of choice because they provide excellent coverage against beta-lactamase-producing strains of *H. influenzae* and most Gram-positive cocci. They have superior tissue penetration and a proven safety profile in pediatric populations, who are most commonly affected. **Analysis of Incorrect Options:** * **Sulphamethoxazole:** Primarily used for UTIs or PCP pneumonia; it lacks the necessary efficacy against the aggressive pathogens causing epiglottitis. * **Chloramphenicol:** Historically used for Hib infections, it is no longer the first line due to its narrow therapeutic index and the risk of severe side effects like aplastic anemia and Gray baby syndrome. * **Clindamycin:** While useful for anaerobic infections or MRSA, it does not provide adequate coverage for *H. influenzae*, the primary pathogen in epiglottitis. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** High fever, "Hot potato" voice, drooling, and the **Tripod position** (leaning forward to open the airway). * **X-ray Finding:** Lateral neck X-ray shows the **"Thumb sign"** (swollen epiglottis). * **Management Priority:** The first priority is **airway management** (intubation or tracheostomy). Do not examine the throat with a tongue depressor, as it may trigger fatal laryngospasm. * **Prophylaxis:** Rifampicin is given to close contacts of Hib-positive cases.

Q: What is the typical resting position of a vocal cord in a cadaver?

Intermediate. ### Explanation The position of the vocal cords is determined by the balance of intrinsic laryngeal muscles. In a **cadaver**, all neuro-muscular activity ceases, leading to a state of complete muscle paralysis. **1. Why "Intermediate" is Correct:** The **Intermediate (Cadaveric) position** is the neutral position where the vocal cord lies approximately **3.5 mm** away from the midline. This occurs because all intrinsic muscles—both adductors (which close the glottis) and abductors (which open it)—are non-functional. Without any muscular pull, the vocal cord assumes this midway point between full abduction and the midline. **2. Analysis of Incorrect Options:** * **Median (0 mm):** The cords are in the midline. This is seen during phonation or in bilateral recurrent laryngeal nerve palsy (where the cricothyroid muscle may still tense the cord). * **Paramedian (1.5 mm):** This is the typical position in **Recurrent Laryngeal Nerve (RLN) palsy**. The cricothyroid muscle (supplied by the Superior Laryngeal Nerve) remains intact and acts as an adductor, pulling the cord closer to the midline than the cadaveric position. * **Full Abduction (7–9 mm):** This occurs during deep inspiration, driven by the active contraction of the **Posterior Cricoarytenoid (PCA)**, the only abductor of the vocal cords. **3. Clinical Pearls for NEET-PG:** * **Semon’s Law:** States that in progressive lesions of the RLN, the abductor fibers are injured first; thus, the cord initially moves to a median/paramedian position before potentially reaching the cadaveric position if the Superior Laryngeal Nerve is also involved. * **Wagner and Grossman Hypothesis:** Explains that if the Superior Laryngeal Nerve is intact, the cord stays paramedian; if both RLN and SLN are paralyzed, the cord moves to the **Intermediate/Cadaveric** position. * **Key Distance:** Remember the "3.5 mm" rule for the intermediate position to distinguish it from the paramedian (1.5 mm).

Question 1

A 3-year-old male child presents with multiple laryngeal papillomas, hoarse voice, and slight airway distress. The papillomas involve the glottis. What is the best treatment?

Accepted Answer

Microlaryngoscopy and excision

Answer

Tracheostomy and observation

Answer

Steroids

Answer

Interferon therapy

Question 2

All of the following are true about pachydermia laryngitis except?

Accepted Answer

Premalignant condition

Answer

Hoarseness of voice

Answer

Involves posterior part of larynx

Answer

Biopsy shows acanthosis and hyperkeratosis

Question 3

What is the most common mode of treatment for laryngomalacia?

Accepted Answer

Reassurance

Answer

Medical management

Answer

Surgical intervention

Answer

Observation

Question 4

A middle-aged male presents with a 2-year history of hoarseness of voice. He has a 30-year smoking history. Examination reveals a reddish area of mucosal irregularity overlying a portion of both vocal cords. Which of the following management options would NOT be indicated?

Accepted Answer

Bilateral cordectomy

Answer

Cessation of smoking

Answer

Microlaryngeal surgery for biopsy

Answer

Regular follow-up

Question 5

All of the following are true about vocal cord nodules except:

Accepted Answer

Commonly occur at the junction of the anterior and middle thirds of the vocal cord

Answer

Caused by phonotrauma

Answer

Common at the junction of the anterior and posterior two-thirds of the vocal cord

Answer

Common in singers and teachers

Question 6

Which of the following can be produced by reflux laryngitis?

Accepted Answer

Subglottic stenosis

Answer

Carcinoma of the larynx

Answer

Cord fixation

Answer

Acute supraglottitis

Question 7

Which of the following is NOT true about supraglottic laryngeal carcinoma?

Accepted Answer

It is the most common site for carcinoma of the larynx.

Answer

Involvement of upper and middle jugular lymph nodes is seen.

Answer

A palpable neck mass is the most common symptom.

Answer

Stage T1 disease can be treated by external beam radiotherapy.

Question 8

What is the drug of choice for the treatment of epiglottitis?

Accepted Answer

Ceftriaxone

Answer

Sulphamethoxazole

Answer

Chloramphenicol

Answer

Clindamycin

Question 9

What is the most common site for a contact ulcer in the larynx?

Accepted Answer

Arytenoids

Answer

Corniculate cartilage

Answer

Anterior one-third of the vocal cord

Answer

Cricoid cartilage

Question 10

What is the typical resting position of a vocal cord in a cadaver?

Accepted Answer

Intermediate

Answer

Median

Answer

Paramedian

Answer

Full Abduction

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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