Diseases of the Larynx Practice Questions

Q: Which of the following subunits is associated with inspiratory stridor?

Supraglottic. ***Supraglottic*** - Obstruction or narrowing in the supraglottic region (above the true vocal cords), such as in **epiglottitis** or **laryngomalacia**, collapses inward during inspiration. - This physiological collapse under negative inspiratory pressure creates characteristic high-pitched airflow limitation known as **inspiratory stridor**. *Glottic* - Lesions affecting the true vocal cords (e.g., bilateral **vocal cord paralysis** or severe webbing) typically cause a relatively fixed obstruction. - Fixed obstruction at the vocal cord level generally results in a **biphasic stridor** (heard equally during both inspiration and expiration). *Subglottic* - Obstruction occurring below the vocal cords at the level of the cricoid cartilage (e.g., **croup** or **subglottic stenosis**). - Since the subglottic area is less compliant than the supraglottic area, it commonly causes a coarse, barking sound and often presents as **biphasic stridor**. *Trachea* - Lower tracheal obstruction may produce a **monophonic wheeze** or sounds related more to expiratory airflow limitation. - High or mid-tracheal lesions, especially if fixed, typically generate a relatively loud **biphasic stridor** rather than purely inspiratory stridor.

Q: Which of the following is true about laryngeal cancer stage T1bNOMO?

Both vocal cords involved, and mobile. ***Both vocal cords involved, and mobile***- The **T1** designation in glottic laryngeal cancer implies that the tumor is strictly limited to the **vocal cords** and that mobility is preserved (i.e., they are **mobile**).- The subsequent **T1b** substage defines tumors that involve **both vocal cords** (e.g., crossing the anterior or posterior commissure) while maintaining normal movement.*Both vocal cords involved and fixed*- **Vocal cord fixation** is a defining feature of **T3** glottic carcinoma, indicating deep invasion into the paralaryngeal space or underlying musculature.- This designation immediately excludes **T1** staging, which strictly requires preserved vocal cord **mobility**.*One vocal cord involved and fixed*- **Fixation** (immobility) places the tumor in **T3** or higher, regardless of tumor size or involvement of one versus both vocal cords.- **T1a** is defined by involvement of only **one vocal cord**, but critically, it must be mobile to be classified as T1.*One vocal cord involved, and mobile*- This specific description corresponds to **T1a** glottic laryngeal cancer, which involves the tumor being confined to the **glottis** and limited to only **one vocal cord**, with normal mobility.

Q: A 72-year-old female smoker presents with a long history of hoarseness and difficulty swallowing. Laryngoscopy and biopsy confirm a large, advanced squamous cell carcinoma that involves both vocal cords and extends into the subglottic region and the thyroid cartilage. The tumor is not amenable to radiation therapy alone. Based on the extent and location of the tumor, which of the following surgical procedures is most appropriate to ensure complete tumor removal with adequate margins and control the disease?

Total laryngectomy. ***Total laryngectomy*** - This procedure is the standard of care for **advanced laryngeal carcinoma (T3/T4a)** when there is extensive involvement, including the **thyroid cartilage invasion** and extension into the **subglottic region**. - Given the tumor's size, bilateral cord involvement, and lack of response to primary radiation, total laryngectomy is required to achieve complete tumor removal with **negative surgical margins**. *Partial laryngectomy* - This technique is generally restricted to **early-stage tumors (T1 or T2)** confined to one part of the larynx without substantial cartilage or subglottic spread. - Attempting a partial resection on a large, bilateral tumor with **cartilage invasion** would result in positive margins and an unacceptable risk of local recurrence. *Emergency tracheostomy* - This is a procedure performed solely to relieve **acute airway obstruction**, which may occur in advanced laryngeal cancer, but it is not a curative treatment for the malignancy itself. - It addresses the symptom (airway compromise) but fails to remove the **squamous cell carcinoma** that is threatening the patient's life. *Submental tracheostomy* - A tracheostomy is an airway management procedure, not a definitive oncologic surgery for removing a large laryngeal tumor. - A standard tracheostomy (for airway placement) is sometimes needed, but placing it specifically in the **submental region** is not the standard location for a permanent tracheostoma following curative total laryngectomy.

Q: Which of the following is shown in the image below?

Steeple sign. ***Steeple sign*** - The image shows a **frontal view of the cervical trachea**, with the subglottic region narrowing inferiorly, creating an inverted V shape, characteristic of the **steeple sign**. - This sign indicates **subglottic narrowing**, usually due to **croup (laryngotracheobronchitis)**, caused by swelling of the tracheal walls. *Thumb sign* - The **thumb sign** is seen on a **lateral neck X-ray** and refers to a swollen **epiglottis** resembling a thumb. - It is indicative of **epiglottitis**, a serious bacterial infection, and would not be visible as a steeple shape in an AP view. *Omega sign* - The **omega sign** refers to the appearance of the epiglottis in **laryngomalacia**, where the epiglottis is **tubular and elongated** with infolded lateral margins. - This is typically seen on **laryngoscopy** rather than a plain radiograph and would not present as the tracheal narrowing shown. *Lyre sign* - The **lyre sign** describes the appearance of the common carotid artery bifurcation, where the internal and external carotid arteries diverge around a **carotid body tumor**, resembling a lyre musical instrument. - This is a vascular sign seen on angiography or cross-sectional imaging and has no relevance to tracheal pathology on a plain neck X-ray.

Q: Which of the following is incorrect about the clinical condition shown below?

Nocturnal cyanosis. ***Nocturnal cyanosis*** - **Nocturnal cyanosis is NOT a typical feature of laryngomalacia**, making this the correct answer to what is incorrect about the condition. Laryngomalacia is characterized by inspiratory stridor due to collapse of supraglottic structures, but it rarely causes cyanosis. - While symptoms may worsen during sleep, frank cyanosis indicates severe obstruction or hypoxemia, which is uncommon in typical laryngomalacia. If present, it suggests severe disease requiring surgical intervention. - Most cases of laryngomalacia are mild and self-limiting without significant oxygen desaturation. *Drooling of saliva* - Drooling is also not a typical feature of laryngomalacia, as the condition involves upper airway collapse, not difficulty with saliva management or swallowing. - However, **nocturnal cyanosis is the better answer** as it more clearly represents an atypical/severe presentation, whereas drooling is simply not associated with the condition at all. *Inspiratory stridor* - **Inspiratory stridor is the hallmark symptom** of laryngomalacia, caused by collapse of supraglottic structures during inspiration, leading to turbulent airflow. - This symptom is typically exacerbated by feeding, crying, agitation, or lying supine, and usually appears within the first 2 weeks to 2 months of life. *Omega-shaped epiglottis* - An **omega-shaped (Ω-shaped) epiglottis is a classic laryngoscopic finding** in laryngomalacia, visible during flexible laryngoscopy. - This anatomical configuration, along with redundant arytenoid mucosa and shortened aryepiglottic folds, contributes to the dynamic collapse during inspiration that causes stridor.

Q: All of the following are correct about the image shown except:

High pitched expiratory stridor. ***High pitched expiratory stridor*** - The image depicts an **omega-shaped epiglottis** and collapsed aryepiglottic folds, consistent with **laryngomalacia**. - Laryngomalacia typically presents with **inspiratory stridor**, not expiratory, resulting from airway collapse during inspiration. - **This is the EXCEPT answer** - high-pitched expiratory stridor is NOT a feature of laryngomalacia. *Omega shaped epiglottis* - The image clearly shows an **omega-shaped epiglottis**, a characteristic feature of **laryngomalacia**. - This anatomical variation contributes to the collapse of supraglottic structures during inspiration. *Cry is normal* - In laryngomalacia, the **vocal cords** themselves are not affected, so the **cry typically remains normal**. - The abnormal sounds (stridor) arise from the supraglottic structures, not the vocal cord function during crying. *10% cases need surgery due to development of OSA or Cor Pulmonale* - While most cases of laryngomalacia are self-limiting, approximately **10% of infants may require surgical intervention** (supraglottoplasty). - This is usually due to severe symptoms like **obstructive sleep apnea (OSA)**, failure to thrive, or the rare development of **cor pulmonale**.

Q: What is the most likely diagnosis shown in the image?

Vocal polyp. ***Vocal polyp*** - The image shows a **pedunculated or sessile lesion** on the vocal fold, often associated with a vascular component or fluid-filled appearance, typical of a vocal polyp. - Vocal polyps are typically **unilateral** and often result from acute vocal trauma or chronic phonotrauma, causing a distinct mass. *Vocal nodule* - Vocal nodules are typically **bilateral, symmetrical lesions** located on the middle third of the vocal folds, resembling calluses or bumps. - They tend to be smaller and firmer, forming due to chronic vocal abuse, unlike the larger, often unilateral lesion seen here. *Laryngomalacia* - Laryngomalacia is a **congenital anomaly** where the laryngeal structures are soft and collapse inward during inspiration, primarily affecting infants. - This condition does not present with a discrete mass on the vocal fold but rather with a generalized malformation of the larynx. *Epiglottitis* - Epiglottitis is an **inflammation and swelling of the epiglottis**, which can be life-threatening due to airway obstruction. - The image displays vocal folds and a lesion, not a swollen, cherry-red epiglottis, which would be located superior to the vocal cords.

Q: A 14-year-old teenager presents with hoarseness of voice. Which of the following is responsible for the lesion shown in the figure?

HPV. ***HPV*** - The image depicts **laryngeal papillomatosis**, characterized by **wart-like lesions** on the vocal cords, which is primarily caused by **Human Papillomavirus (HPV)** types 6 and 11. - In teenagers, this condition is typically **juvenile-onset recurrent respiratory papillomatosis**, acquired perinatally from an infected mother. *EBV* - **Epstein-Barr Virus (EBV)** is associated with infectious mononucleosis, certain lymphomas, and nasopharyngeal carcinoma, but not typically with laryngeal papillomas. - Oral manifestations of EBV infection, like **oral hairy leukoplakia**, are distinct from benign laryngeal growths. *HIV* - **Human Immunodeficiency Virus (HIV)** causes immunosuppression, increasing susceptibility to various opportunistic infections and cancers, but it does not directly cause laryngeal papillomatosis. - While HIV-positive individuals may have co-infection with HPV, HPV is the direct cause of the papillomas. *HSV* - **Herpes Simplex Virus (HSV)** is known for causing oral and genital herpes lesions, characterized by **vesicles and ulcers**. - HSV does not typically cause the **papillomatous, proliferative lesions** seen in the image, which are characteristic of HPV infection.

Q: A 60-year-old smoker presents with history of weight loss and thyroid swelling which is hard in consistency. Surgery was performed after which nerve B and D shown in the diagram got involved. All are true about the resultant condition except:

Askew position of vocal cord. ***Askew position of vocal cord*** - Vocal cord paralysis typically results in the **paramedian or median position** of the vocal cords, not an "askew" position, which is not a recognized clinical term for vocal cord positioning. - The nerves B and D are the **recurrent laryngeal nerves**, which innervate all intrinsic muscles of the larynx except the cricothyroid. Damage to both recurrent laryngeal nerves would lead to **bilateral vocal cord paralysis**. *Most common symptom is dyspnea and stridor* - **Bilateral recurrent laryngeal nerve palsy** leads to the vocal cords being fixed in a paramedian position, which significantly narrows the glottic opening. - This narrow airway causes severe **dyspnea** (difficulty breathing) and inspiratory **stridor** (a high-pitched crowing sound during inhalation), which are life-threatening symptoms requiring immediate intervention. *Most common cause is thyroid surgery* - The most common cause of **bilateral recurrent laryngeal nerve paralysis** is **thyroid surgery** due to iatrogenic trauma or transection of the nerves during the procedure. - Other causes include **malignant infiltration** of the thyroid or surrounding structures, and rarely **bilateral intubation trauma**. - Given the clinical scenario of a patient with thyroid swelling undergoing surgery, iatrogenic injury during thyroidectomy is the most likely cause. *Kashima operation with carbon dioxide laser* - The **Kashima operation**, involving posterior cordectomy with a **CO2 laser**, is a surgical procedure used to widen the glottic airway in cases of bilateral vocal cord paralysis. - This procedure aims to create a larger breathing passage by removing a portion of the posterior vocal cord, thereby alleviating dyspnea and stridor.

Question 1

Which of the following subunits is associated with inspiratory stridor?

Accepted Answer

Supraglottic

Answer

Glottic

Answer

Trachea

Answer

Subglottic

Question 2

Which of the following is true about laryngeal cancer stage T1bNOMO?

Accepted Answer

Both vocal cords involved, and mobile

Answer

Both vocal cords involved and fixed

Answer

One vocal cord involved and fixed

Answer

One vocal cord involved, and mobile

Question 3

A 72-year-old female smoker presents with a long history of hoarseness and difficulty swallowing. Laryngoscopy and biopsy confirm a large, advanced squamous cell carcinoma that involves both vocal cords and extends into the subglottic region and the thyroid cartilage. The tumor is not amenable to radiation therapy alone. 
Based on the extent and location of the tumor, which of the following surgical procedures is most appropriate to ensure complete tumor removal with adequate margins and control the disease?

Accepted Answer

Total laryngectomy

Answer

Emergency tracheostomy

Answer

Submental tracheostomy

Answer

Partial laryngectomy

Question 4

Which of the following is shown in the image below?

Accepted Answer

Steeple sign

Answer

Thumb sign

Answer

Omega sign

Answer

Lyre sign

Question 5

All are correct about the procedure performed in the patient except:

Accepted Answer

Skin incision is a vertical midline incision from cricoid cartilage to suprasternal notch

Answer

Skin incision is not sutured to prevent surgical emphysema

Answer

Tracheal incision is a transverse incision starting from the first tracheal ring

Answer

Performed under general anesthesia in infants

Question 6

Which of the following is incorrect about the clinical condition shown below?

Accepted Answer

Nocturnal cyanosis

Answer

Drooling of saliva

Answer

Inspiratory stridor

Answer

Omega epiglottis

Question 7

All of the following are correct about the image shown except:

Accepted Answer

High pitched expiratory stridor

Answer

Omega shaped epiglottis

Answer

Cry is normal

Answer

10% cases need surgery due to development of OSA or Cor Pulmonale

Question 8

What is the most likely diagnosis shown in the image?

Accepted Answer

Vocal polyp

Answer

Vocal nodule

Answer

Laryngomalacia

Answer

Epiglottitis

Question 9

A 14-year-old teenager presents with hoarseness of voice. Which of the following is responsible for the lesion shown in the figure?

Accepted Answer

HPV

Answer

EBV

Answer

HIV

Answer

HSV

Question 10

A 60-year-old smoker presents with history of weight loss and thyroid swelling which is hard in consistency. Surgery was performed after which nerve B and D shown in the diagram got involved. All are true about the resultant condition except:

Accepted Answer

Askew position of vocal cord

Answer

Most common symptom is dyspnea and stridor

Answer

Most common cause is thyroid surgery

Answer

Kashima operation with carbon dioxide laser

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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