Diseases of the Larynx Practice Questions

Q: A 10-year-old girl complains of hoarseness and stridor. Ambulatory pH monitoring is normal. Laryngoscopy image shows:

Recurrent respiratory papillomatosis. ***Recurrent respiratory papillomatosis*** - The image shows a **wart-like lesion** on the vocal cord, which is characteristic of **recurrent respiratory papillomatosis (RRP)**, especially in a child with hoarseness and stridor. - RRP is caused by the **human papillomavirus (HPV)** and can affect the airway, leading to vocal changes and breathing difficulties. - This is the most common benign laryngeal tumor in children and typically presents with progressive hoarseness and stridor. *Vocal cord polyp* - A vocal cord polyp is typically a **stalked, unilateral lesion**, often associated with vocal trauma or heavy voice use, and usually appears as a fluid-filled sac. - While it can cause hoarseness, the appearance in the image with multiple, nodular growths in the glottic area is less consistent with a single polyp. - Polyps are more common in adults than children. *Vocal cord nodules* - Vocal cord nodules are typically **bilateral, symmetrical lesions** located at the junction of the anterior and middle third of the vocal cords, resembling calluses. - They are usually caused by **voice abuse** (e.g., screaming, prolonged singing) and are less likely to present with the cauliflower-like appearance shown. - Nodules appear smooth and do not have the exophytic, warty appearance of papillomas. *Intubation granuloma* - An intubation granuloma is a **benign lesion** that forms at the posterior true vocal cord or arytenoid cartilage due to **mucosal trauma** from endotracheal intubation. - This patient's history does not suggest recent intubation, and the appearance in the image is more consistent with papilloma than a granuloma. - Granulomas typically appear as smooth, pedunculated masses at the posterior glottis.

Q: A 30-year-old vegetable vendor complains of repeated episodes of hoarseness and pain in the neck on speaking. The laryngoscopy image of the patient shows:

Vocal nodules. ***Vocal nodules*** - The image shows **bilateral, symmetrical lesions** on the vocal cords, characteristic of vocal nodules, commonly known as "singer's nodes" or "screamer's nodes." - The patient's profession as a **vegetable vendor**, involving frequent and loud speaking, is a classic risk factor for vocal misuse leading to nodule formation. *Vocal polyp* - A vocal polyp is typically a **unilateral lesion**, often larger and more reddish than nodules. - While it can also cause hoarseness, the **bilateral and symmetrical nature** seen in the image points away from a polyp. *Reinke's edema* - Reinke's edema involves diffuse **swelling and fluid accumulation** in Reinke's space (superficial lamina propria) of both vocal cords, often associated with smoking. - The image does not show the characteristic **"sac-like" or "baggy" appearance** of generalized edema. *Intubation granuloma* - An intubation granuloma results from **trauma during endotracheal intubation** and is typically located on the posterior aspect of the vocal cords (arytenoid area). - The patient's history does not mention intubation, and the **location and appearance** in the image are not typical for a granuloma.

Q: The following image shows:

Respiratory papillomatosis. ***Respiratory papillomatosis*** - The image displays multiple **wart-like growths** on the vocal cords, characteristic of **respiratory papillomatosis**, which is caused by the **human papillomavirus (HPV)**. - These lesions often have an **irregular, cauliflower-like appearance** and can recur even after removal, making it a challenging condition to manage. *Vocal nodule* - Vocal nodules are typically **bilateral, symmetrical lesions** located at the junction of the anterior and middle thirds of the vocal cords. - They are usually **smooth, small, and whitish**, resulting from chronic vocal abuse, unlike the irregular and multiple growths seen in the image. *Vocal polyp* - Vocal polyps are typically **unilateral lesions** that can appear as sessile or pedunculated masses on a vocal cord. - They are often **larger than nodules** and may have a reddish or gelatinous appearance, but they usually occur singly, not as multiple diffuse growths like those pictured. *TB of vocal cords* - Tuberculosis of the vocal cords often presents with **ulcerative lesions**, granulomas, or diffuse inflammation, and may be accompanied by other signs of pulmonary TB. - The lesions caused by TB are generally **not papillomatous** or wart-like in nature, differentiating them from the appearance in the image.

Q: Which is the most common laryngeal abnormality that produces laryngeal stridor in a newborn?

Laryngomalacia. ***Laryngomalacia*** - **Laryngomalacia** is the most common cause of **congenital laryngeal stridor**, accounting for 60-70% of cases. - It results from the **floppiness of supraglottic structures** (epiglottis and arytenoids) that collapse inward during inspiration, causing stridor. *Congenital vocal cord paralysis* - While it can cause stridor, **congenital vocal cord paralysis** is much less common than laryngomalacia. - It typically results from neurological issues, and the stridor quality may differ. *Congenital web* - A **congenital web** is a rare cause of stridor, usually presenting with a **high-pitched persistent stridor** and often a weak cry. - The severity depends on the extent of the web across the glottis. *Congenital subglottic stenosis* - **Congenital subglottic stenosis** is the third most common cause of congenital stridor (after laryngomalacia and vocal cord paralysis). - It is characterized by narrowing of the airway below the vocal cords and often presents with biphasic stridor and recurrent croup-like symptoms.

Q: A localized nodule of squamous cell carcinoma in the vocal cord is best treated by

Laser therapy. ***Laser therapy (Transoral Laser Microsurgery)*** - **CO2 laser excision** is an excellent first-line treatment for localized T1a squamous cell carcinoma of the vocal cord, offering **>90% cure rates**. - Advantages include: **precise tumor removal**, immediate pathological assessment with margin evaluation, **excellent voice preservation**, and shorter treatment duration compared to radiotherapy. - **Transoral laser microsurgery (TLM)** allows for cord-sparing procedures that maintain vocal function while achieving complete oncological resection. *Radiotherapy* - **Important Note:** **Radiotherapy is EQUALLY effective** as laser therapy for early T1 glottic cancer, with comparable **5-year local control rates (>90%)** and voice quality outcomes. - Both laser surgery and radiotherapy are **guideline-recommended first-line treatments** (NCCN, ESMO guidelines). - Choice between the two depends on tumor characteristics (anterior commissure involvement), patient preference, institutional expertise, and functional outcomes. - In examination contexts, laser therapy may be preferred as it provides histopathological confirmation and is often considered more definitive for "localized nodules." *Cryosurgery* - **Cryosurgery** is rarely used for vocal cord lesions due to **unpredictable tissue destruction**, potential for severe **vocal cord scarring**, and inability to obtain tissue for pathological margin assessment. - Not a standard treatment option for laryngeal cancer. *Surgical excision* - This term is ambiguous as **laser excision IS a form of surgical excision**. - If referring to **open surgical approaches** (laryngofissure, cordectomy via external approach), these are more invasive than transoral laser surgery and are reserved for larger tumors or salvage situations. - Traditional "cold steel" endoscopic excision is less precise than laser and can cause more trauma and scarring.

Q: Which among the following is not used in post laryngectomy rehabilitation?

Tracheostomy tube. ***Tracheostomy tube*** - Following total laryngectomy, the **trachea is permanently diverted** to form a permanent stoma in the neck for breathing. - In the context of **post-laryngectomy rehabilitation**, the focus is on **voice restoration** methods rather than airway management devices. - While laryngectomy tubes or stoma buttons may be used temporarily for **stoma care** (preventing stenosis, maintaining patency), traditional **tracheostomy tubes are not part of voice rehabilitation** protocols. - The patient breathes directly through the permanent stoma, and rehabilitation centers on restoring communication ability. *Esophageal speech* - **Esophageal speech** is a voice rehabilitation method where air is injected into the esophagus and then expelled, vibrating the pharyngoesophageal segment to produce sound. - It requires no external devices, only extensive training, and can provide functional voice for communication. - This is one of the **three main voice restoration options** after laryngectomy. *Tracheoesophageal puncture* - **Tracheoesophageal puncture (TEP)** with voice prosthesis is the **gold standard** for voice rehabilitation post-laryngectomy. - A small fistula is created between trachea and esophagus, and a one-way valve (voice prosthesis) is inserted. - Air from the lungs is diverted through the prosthesis into the esophagus, vibrating the pharyngoesophageal segment to produce speech. - Provides the **most natural-sounding voice** among rehabilitation options. *Electrolarynx* - An **electrolarynx** is an external, battery-operated device held against the neck or placed intraorally that generates vibrations. - The vibrations are articulated by the mouth and tongue to produce speech. - Provides **immediate communication** post-laryngectomy, though the voice quality is mechanical or robotic.

Q: Not true about glottic carcinoma

Has worst prognosis. ***Has worst prognosis*** - Glottic carcinoma generally has a **good prognosis** due to its early presentation with hoarseness and relative lack of lymphatic dissemination. - The statement that it has the **worst prognosis** among laryngeal carcinomas is incorrect; supraglottic and subglottic carcinomas often have poorer prognoses. *Is most common site in carcinoma larynx* - The **glottis** (true vocal cords) is indeed the **most common site** for laryngeal squamous cell carcinoma, accounting for about 60-70% of cases. - This anatomical location is prone to neoplastic changes due to exposure to carcinogens. *Presents early* - Glottic carcinoma typically presents **early** with **hoarseness of voice** as the tumor interferes with vocal cord vibration. - This early symptom often leads to prompt medical attention, allowing for early diagnosis and treatment. *Most common in males* - Laryngeal carcinoma, including glottic carcinoma, is significantly **more common in males** than females, with a male-to-female ratio of about 4:1. - This gender disparity is primarily attributed to higher rates of smoking and alcohol consumption in men. *Has good prognosis due to least lymphatic supply.* - The **glottis** has a relatively **sparse lymphatic drainage** compared to the supraglottis and subglottis. - This limited lymphatic supply leads to a lower risk of **early nodal metastasis**, contributing to the overall good prognosis.

Q: Stage IVa with thyroid cartilage invasion in laryngeal carcinoma is treated with:

Total laryngectomy with radiotherapy. ***Total laryngectomy with radiotherapy*** - **Stage IVa laryngeal carcinoma** with **thyroid cartilage invasion** is considered advanced disease requiring aggressive treatment. - **Multimodal therapy** combining surgical resection (total laryngectomy) to remove the tumor and adjuvant radiotherapy to address microscopic disease and reduce recurrence is the standard of care. *Total laryngectomy* - While a **total laryngectomy** is necessary to remove the primary tumor with cartilage invasion, it often requires additional (adjuvant) therapy like radiation to improve local control and survival rates. - Relying solely on surgery for **Stage IVa disease** may not adequately address potential microscopic spread, leading to higher recurrence rates. *Radiotherapy* - **Radiotherapy alone** is typically reserved for early-stage laryngeal cancers or as a palliative measure for advanced, unresectable disease. - In Stage IVa with **thyroid cartilage invasion**, radiation alone is insufficient due to the bulk of the disease and high risk of local recurrence. *Hemilaryngectomy* - A **hemilaryngectomy** is a partial removal of the larynx, suitable for much smaller, early-stage tumors that are confined to one side of the larynx, without cartilage invasion. - It is inadequate for **Stage IVa disease** with cartilage invasion due to the extensive nature of the tumor.

Q: Topical mitomycin C is used to aid the following treatment:

Treatment of laryngotracheal stenosis. ***Treatment of laryngotracheal stenosis*** - **Mitomycin C** is an **antimitotic** agent that inhibits DNA synthesis, reducing **fibroblast proliferation** and collagen synthesis. - In laryngotracheal stenosis, it is applied topically to inhibit scar tissue formation and recurrence after surgical or endoscopic intervention. *Endoscopic treatment of angiofibroma* - **Angiofibromas** are benign vascular tumors; their treatment focuses on surgical resection, often with **preoperative embolization** to reduce bleeding. - **Mitomycin C** is not typically used for angiofibroma, as it does not address the vascular nature or growth pattern of this tumor effectively. *Skull base osteomyelitis* - **Skull base osteomyelitis** is an aggressive bacterial infection of the skull base, primarily treated with long-term **antibiotics** and sometimes surgical debridement. - **Mitomycin C**, an antineoplastic agent, has no role in treating bacterial infections of bone. *Tonsillectomy* - **Tonsillectomy** is a surgical procedure to remove the tonsils, usually performed for recurrent tonsillitis or sleep-disordered breathing. - **Mitomycin C** is not indicated for tonsillectomy; its use would not offer benefits and could potentially hinder wound healing or cause adverse effects.

Q: Stridor in an infant is most commonly due to:

Laryngomalacia. ***Laryngomalacia*** - **Laryngomalacia** is the most common cause of **congenital inspiratory stridor** in infants, resulting from supraglottic laryngeal structures collapsing inward during inspiration. - The stridor is typically **worse when crying, feeding, or lying supine** and usually improves spontaneously by 12-18 months of age. *Foreign body aspiration* - While foreign body aspiration can cause **acute stridor**, it is an event-specific occurrence, not a persistent condition from birth, and often presents with **sudden onset choking and respiratory distress**. - Its incidence is higher in **toddlers and older children** who are mobile and exploring their environment, rather than infants. *Diphtheria* - **Diphtheria** is a rare cause of stridor due to widespread vaccination and is characterized by a **"bull neck"** and a **pseudomembrane in the pharynx**, which is distinct from the typical presentation of laryngomalacia. - The stridor associated with Diphtheria is typically progressive and can lead to severe **respiratory obstruction and systemic toxicity**. *Acute epiglottitis* - **Acute epiglottitis** typically presents with sudden onset of **high fever, dysphagia, drooling, and muffled voice** in older children, rather than stridor from birth in an infant. - Due to **Hib vaccine**, acute epiglottitis is now very rare and its stridor is usually rapidly progressive and life-threatening.

Question 1

A 10-year-old girl complains of hoarseness and stridor. Ambulatory pH monitoring is normal. Laryngoscopy image shows:

Accepted Answer

Recurrent respiratory papillomatosis

Answer

Vocal cord polyp

Answer

Vocal cord nodules

Answer

Intubation granuloma

Question 2

A 30-year-old vegetable vendor complains of repeated episodes of hoarseness and pain in the neck on speaking. The laryngoscopy image of the patient shows:

Accepted Answer

Vocal nodules

Answer

Vocal polyp

Answer

Reinke's edema

Answer

Intubation granuloma

Question 3

The following image shows:

Accepted Answer

Respiratory papillomatosis

Answer

Vocal nodule

Answer

Vocal polyp

Answer

TB of vocal cords

Question 4

Which is the most common laryngeal abnormality that produces laryngeal stridor in a newborn?

Accepted Answer

Laryngomalacia

Answer

Congenital vocal cord paralysis

Answer

Congenital web

Answer

Congenital subglottic stenosis

Question 5

A localized nodule of squamous cell carcinoma in the vocal cord is best treated by

Accepted Answer

Laser therapy

Answer

Cryosurgery

Answer

Radiotherapy

Answer

Surgical excision

Question 6

Which among the following is not used in post laryngectomy rehabilitation?

Accepted Answer

Tracheostomy tube

Answer

Esophageal speech

Answer

Tracheoesophageal puncture

Answer

Electrolarynx

Question 7

Not true about glottic carcinoma

Accepted Answer

Has worst prognosis

Answer

Is most common site in carcinoma larynx

Answer

Presents early

Answer

Most common in males

Question 8

Stage IVa with thyroid cartilage invasion in laryngeal carcinoma is treated with:

Accepted Answer

Total laryngectomy with radiotherapy

Answer

Total laryngectomy

Answer

Radiotherapy

Answer

Hemilaryngectomy

Question 9

Topical mitomycin C is used to aid the following treatment:

Accepted Answer

Treatment of laryngotracheal stenosis

Answer

Endoscopic treatment of angiofibroma

Answer

Skull base osteomyelitis

Answer

Tonsillectomy

Question 10

Stridor in an infant is most commonly due to:

Accepted Answer

Laryngomalacia

Answer

Foreign body aspiration

Answer

Diphtheria

Answer

Acute epiglottitis

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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