Diseases of the Larynx Practice Questions

Q: Wagner's classification is related to:

Vocal cord palsy. ***Vocal cord palsy*** - **Wagner's classification** is a system used to grade the severity and prognosis of **vocal fold paralysis**. - It assesses the position, mobility, and clinical impact of **vocal cord dysfunction**. *Palatal palsy* - **Palatal palsy** involves the muscles of the soft palate and is not directly assessed by Wagner's classification. - This condition affects **swallowing and speech resonance**, which are distinct from vocal cord paralysis. *Facial palsy* - **Facial palsy**, such as **Bell's palsy**, affects the facial muscles and is classified using systems like the **House-Brackmann scale**. - It is unrelated to voice or vocal cord function. *Hypoglossal palsy* - **Hypoglossal palsy** impacts the **tongue muscles**, leading to deviation or atrophy, which affects articulation and swallowing. - It does not involve the vocal cords or larynx, thus unrelated to Wagner's classification.

Q: The preferred treatment of verrucous carcinoma of the larynx is:

Endoscopic removal. ***Endoscopic removal*** - Verrucous carcinoma is a **well-differentiated squamous cell carcinoma** with a **low metastatic potential**, making local control the primary goal. - **Endoscopic removal** (e.g., CO2 laser excision) allows for precise removal with good functional outcomes and is often curative for early-stage lesions. *Electron beam therapy* - While radiation can be used for laryngeal cancers, verrucous carcinoma has a **tendency to dedifferentiate (become more aggressive)** or develop **anaplastic transformation** after radiation therapy. - This can lead to a more aggressive, conventional squamous cell carcinoma with poorer prognosis, making it a less preferred primary treatment. *Total laryngectomy* - **Total laryngectomy** is a highly morbid procedure that involves the complete removal of the larynx. - It is reserved for extensive, deeply infiltrative tumors or cases where other treatments have failed, which is typically not the case for most verrucous carcinomas. *Partial laryngectomy* - **Partial laryngectomy** involves removing part of the larynx, aiming to preserve voice and swallowing function. - This is an option for certain laryngeal cancers, but for verrucous carcinoma, less invasive endoscopic removal is often sufficient and preferred given its non-invasive nature.

Q: Which of the following is a precancerous lesion?

Keratosis of larynx. ***Keratosis of larynx*** - **Keratosis of the larynx**, particularly with **dysplasia**, is considered a **precancerous lesion** due to the potential for malignant transformation into squamous cell carcinoma [1]. - It involves abnormal thickening and keratinization of the laryngeal mucosa, often linked to irritants like **smoking** and **alcohol** [1]. *Laryngitis sicca* - This condition involves **dryness and crusting of the laryngeal mucosa**, typically due to environmental factors or systemic drying conditions. - While uncomfortable, it is generally an **inflammatory** condition and not considered precancerous. *Scleroma larynx* - **Laryngeal scleroma** is a chronic inflammatory condition caused by infection with **Klebsiella rhinoscleromatis**, leading to granulomatous changes and fibrosis. - It results in progressive airway obstruction but is a bacterial infection and **not a precancerous lesion**. *Pachydermia of larynx* - **Pachydermia of the larynx** refers to a benign thickening of the laryngeal mucosa, often in the interarytenoid region, typically due to **chronic irritation** or reflux. - Although it indicates chronic inflammation and hyperkeratosis, it is generally considered a **benign reactive change** rather than a true precancerous condition, unless significant dysplasia is also present (which would classify it under keratosis). **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 746-747.

Q: Treatment of choice for carcinoma larynx T1N0M0 stage -

External beam radiotherapy. ***External beam radiotherapy*** - For **T1N0M0 laryngeal carcinoma**, EBRT is the **treatment of choice** as it provides excellent **local control rates (>90%)** while completely **preserving voice quality**. - It is **non-invasive** and avoids surgical complications, making it preferred over surgery for **early-stage glottic cancer** in examination contexts. *Surgery & radiotherapy* - **Combined modality treatment** is reserved for **locally advanced disease (T3-T4)** or **node-positive cases (N+)**, not for early T1N0M0 stage. - Using both treatments for T1 disease would cause **unnecessary morbidity** and **voice impairment** without improving outcomes. *Surgery* - **Transoral laser microsurgery** or **cordectomy** are effective alternatives but considered **secondary choice** in exam contexts for T1N0M0. - While equally effective, surgery carries **operative risks** and potential for **voice quality changes** compared to radiotherapy. *Radioactive implants* - **Brachytherapy** can be used for early glottic cancer but requires **specialized centers** and expertise. - **External beam radiotherapy** is more widely available and has **extensive outcome data** making it the preferred radiotherapy modality.

Q: A tracheostomised patient, with Portex tracheostomy tube, in the ward, developed sudden complete blockage of the tube. Which of the following is the best next step in the management -

Immediate removal of the tracheostomy tube. ***Immediate removal of the tracheostomy tube*** - In cases of **sudden complete tracheostomy tube blockage**, the primary concern is airway patency. Removing the tube is the quickest way to re-establish an airway, as the **tracheostomy stoma** will likely provide a path for breathing. - Delaying removal for suctioning or other interventions can lead to **critical hypoxia** and respiratory arrest if the blockage is total. *Suction of tube with saline* - While suctioning is a routine part of tracheostomy care, using saline to clear a **completely blocked tube** is unlikely to be effective and will delay definitive airway management. - The blockage, if complete and sudden, suggests a solid or highly viscous obstruction that saline alone cannot quickly resolve, potentially worsening the situation by pushing the obstruction deeper. *Suction of tube with sodium bicarbonate* - Sodium bicarbonate can be used for mucolytic purposes in some respiratory conditions, but it is not an immediate solution for a **sudden complete airway obstruction**. - Its action is too slow, and attempting to instill it into a completely blocked tube not only wastes critical time but would also be ineffective in rapidly clearing the blockage. *Jet ventilation* - Jet ventilation requires a patent airway for effective gas exchange, which is absent in a **completely blocked tracheostomy tube**. - Attempting **jet ventilation** through a blocked tube or directly into the stoma without first clearing the primary obstruction would be ineffective and could potentially cause **barotrauma**.

Q: Most common cause of intermittent stridor in a 10-day-old child shortly after birth is:

Laryngomalacia. ***Laryngomalacia*** - This is the **most common cause** of congenital stridor, typically becoming noticeable within the first few weeks of life, consistent with a 10-day-old child. - The stridor is characteristically **intermittent**, worsens with crying or feeding, and improves when prone, due to the collapse of supraglottic structures. *Hypertrophy of turbinate* - While nasal issues can cause **stertor** (a snoring sound), hypertrophy of turbinates is not a common cause of stridor in an infant. - **Stridor** originates from the larynx or trachea, not the nasal passages. *Foreign body* - An aspirated foreign body would typically cause **acute-onset stridor** that is often continuous and associated with choking or coughing spells, rather than intermittent symptoms starting shortly after birth. - This is a less likely etiology for intermittent stridor developing within the first two weeks of life. *Vocal nodule* - Vocal nodules are generally associated with **hoarseness** or a change in voice quality, and typically require chronic vocal abuse to develop. - They are exceptionally rare in neonates and would not present as intermittent stridor.

Q: All are true about tracheostomy tube except -

Removal of metallic tube in every 2-3 days. ***Removal of metallic tube in every 2-3 days*** - This statement is **false**. Metallic tracheostomy tubes, particularly Jackson tubes, are designed for **long-term placement** and typically remain in situ for extended periods (weeks to months). - The inner cannula is removed regularly for cleaning, but the outer metallic tube itself is not removed every 2-3 days as this would cause unnecessary trauma to the stoma. - Regular cleaning of the inner cannula maintains airway hygiene without disturbing the outer tube. *Made up of silver or stainless steel* - This statement is **true**. Traditional Jackson tracheostomy tubes are made of **silver**, which provides excellent durability, biocompatibility, and antimicrobial properties. - Modern metallic tubes may also be made of **stainless steel**, which can be sterilized and reused. - These materials have smooth surfaces that minimize tissue irritation and allow for long-term use. *Jackson's tube has 2 lumens* - This statement is **true**. Jackson tracheostomy tubes have a **double lumen design** consisting of an outer cannula that remains in the stoma and an **inner cannula** that can be removed for cleaning. - This design allows for maintenance of airway hygiene without disturbing the outer cannula, reducing the risk of accidental decannulation and stoma trauma. *Cuffed tube is used to prevent aspiration of pharyngeal secretion* - This statement is **true**. **Cuffed tracheostomy tubes** have an inflatable cuff that creates a seal in the trachea, primarily to **prevent aspiration** of oropharyngeal secretions and gastric contents into the lower respiratory tract. - The cuff also ensures effective positive pressure ventilation by preventing air leakage around the tube during mechanical ventilation.

Q: Most common benign lesion of vocal cord in pediatric age group is

Juvenile papillomatosis. ***Juvenile papillomatosis*** - This condition, caused by the **human papillomavirus (HPV)**, is the most common benign laryngeal tumor in children. - It presents with **recurrent wart-like lesions** on the vocal cords, leading to hoarseness and airway obstruction. *Chondroma* - This is a rare, **benign cartilaginous tumor** that can affect the larynx, but it is exceedingly uncommon in children. - It is more commonly seen in adults and typically arises from the **cricoid cartilage**. *Granular cell tumor* - This is a rare, usually benign tumor originating from **Schwann cells**, which can occur in various locations including the larynx. - It is much more common in **adults** and is distinctly rare in the pediatric age group. *Solitary papilloma* - While papillomas can affect the vocal cords, the term "solitary papilloma" more commonly refers to the **adult form of papillomatosis** (often single lesions) rather than the multiple, recurrent lesions seen in children. - In children, the lesions are typically **multiple and recurrent**, hence "juvenile" and "papillomatosis" (multiple papillomas).

Q: True about recurrent respiratory papillomatosis (multiple papillomatosis) -

HPV is causative agent. ***HPV is causative agent*** - **Human papillomavirus (HPV)** is the primary etiologic agent for recurrent respiratory papillomatosis (RRP), also known as laryngeal papillomatosis. - HPV types **6** and **11** are most commonly associated with RRP (>90% of cases), leading to benign, wart-like growths in the respiratory tract. - This is the most fundamental and defining characteristic of RRP. *It is premalignant* - RRP is a **benign** condition, not a premalignant lesion. - Malignant transformation is extremely rare (<1%), typically associated with HPV types **16** and **18**, radiation exposure, or chronic inflammation [1]. - The vast majority of cases remain benign throughout, so classifying RRP as "premalignant" is incorrect. *Surgical excision is treatment of choice* - While **surgical excision** (laser surgery, microdebrider) is indeed the primary/mainstay treatment for RRP to debulk lesions and maintain airway patency, this statement is technically true. - However, in the context of identifying the "most characteristic" feature, HPV etiology is more fundamental than treatment modality. - Adjuvant therapies like **bevacizumab**, **cidofovir**, or **interferon** may be used for recurrent cases but are not first-line. *It can occur at any age* - This is technically true - RRP exhibits a **bimodal age distribution** with juvenile-onset RRP (JORRP, peak before age 5) and adult-onset RRP (AORRP, peak 20-40 years). - However, the bimodal pattern means it has specific age predilections rather than uniform distribution across all ages. - HPV etiology remains the more definitive characteristic. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 746-747.

Q: A high tracheostomy may be indicated in:

Severe bilateral vocal cord paralysis. ***Severe bilateral vocal cord paralysis*** - **High tracheostomy** may be indicated in severe bilateral vocal cord paralysis, particularly when both cords are paralyzed in the **median (adducted) position**, causing critical airway obstruction. - A high tracheostomy is performed at the level of the **2nd or 3rd tracheal ring**, closer to the site of obstruction at the glottic level, providing immediate airway access. - This can serve as temporary relief while definitive treatments like **arytenoidectomy, cordectomy, or vocal cord lateralization** are planned. - In emergency situations, high tracheostomy or cricothyroidotomy may be life-saving. *Advanced carcinoma of the larynx* - High tracheostomy is **contraindicated** in laryngeal carcinoma as it may: - Transect through tumor tissue - Cause tumor seeding in the tracheal stoma - Compromise subsequent **total laryngectomy** procedures - **Low tracheostomy** (below the tumor, at 4th-5th tracheal ring) is the standard approach to secure the airway while avoiding tumor interference. *Chronic scleroma involving the larynx* - Scleroma typically causes **subglottic stenosis** and involves extensive tracheal disease. - **Low tracheostomy** is preferred to bypass the diseased area completely. - A high tracheostomy would be too close to the pathological process, risking inadequate airway and complications. *Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)* - Tracheostomy is generally **avoided** in RRP due to the significant risk of **seeding papillomas** into the tracheal stoma and lower airways. - Management focuses on **repeated endoscopic laser ablation** or surgical excision to preserve laryngeal function. - If tracheostomy is absolutely necessary, meticulous technique and close follow-up are required.

Question 1

Wagner's classification is related to:

Accepted Answer

Vocal cord palsy

Answer

Palatal palsy

Answer

Facial palsy

Answer

Hypoglossal palsy

Question 2

The preferred treatment of verrucous carcinoma of the larynx is:

Accepted Answer

Endoscopic removal

Answer

Electron beam therapy

Answer

Total laryngectomy

Answer

Partial laryngectomy

Question 3

Which of the following is a precancerous lesion?

Accepted Answer

Keratosis of larynx

Answer

Laryngitis sicca

Answer

Scleroma larynx

Answer

Pachydermia of larynx

Question 4

Treatment of choice for carcinoma larynx T1N0M0 stage -

Accepted Answer

External beam radiotherapy

Answer

Surgery

Answer

Radioactive implants

Answer

Surgery & radiotherapy

Question 5

A tracheostomised patient, with Portex tracheostomy tube, in the ward, developed sudden complete blockage of the tube. Which of the following is the best next step in the management -

Accepted Answer

Immediate removal of the tracheostomy tube

Answer

Suction of tube with saline

Answer

Suction of tube with sodium bicarbonate

Answer

Jet ventilation

Question 6

Most common cause of intermittent stridor in a 10-day-old child shortly after birth is:

Accepted Answer

Laryngomalacia

Answer

Hypertrophy of turbinate

Answer

Foreign body

Answer

Vocal nodule

Question 7

All are true about tracheostomy tube except -

Accepted Answer

Removal of metallic tube in every 2-3 days

Answer

Jackson's tube has 2 lumens

Answer

Cuffed tube is used to prevent aspiration of pharyngeal secretion

Answer

Made up of silver or stainless steel

Question 8

Most common benign lesion of vocal cord in pediatric age group is

Accepted Answer

Juvenile papillomatosis

Answer

Chondroma

Answer

Granular cell tumor

Answer

Solitary papilloma

Question 9

True about recurrent respiratory papillomatosis (multiple papillomatosis) -

Accepted Answer

HPV is causative agent

Answer

It is premalignant

Answer

Surgical excision is treatment of choice

Answer

It can occur at any age

Question 10

A high tracheostomy may be indicated in:

Accepted Answer

Severe bilateral vocal cord paralysis

Answer

Advanced carcinoma of the larynx

Answer

Chronic scleroma involving the larynx

Answer

Recurrent respiratory papillomatosis (multiple papillomatosis of the larynx)

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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