Diseases of the Larynx Practice Questions

Q: What is the commonest cause of hoarseness of voice in an elderly man with a duration of more than 3 months?

Cancer of the larynx. **Explanation:** In any elderly patient, particularly a male with a history of smoking or alcohol use, **persistent hoarseness of voice (dysphonia) for more than 3 weeks** must be considered **Carcinoma of the Larynx** until proven otherwise. The duration of 3 months in this clinical scenario strongly points toward a progressive, neoplastic process rather than an inflammatory or self-limiting one. **Analysis of Options:** * **A. Cancer of the Larynx (Correct):** Glottic cancer (vocal cord) is the most common site and presents early with hoarseness. In the elderly, the risk of malignancy increases significantly, making it the most critical and common diagnosis to rule out in chronic cases. * **B. Chronic Bronchitis:** While it may coexist in smokers, it primarily presents with a productive cough. It does not directly cause hoarseness unless associated with secondary laryngeal irritation or a concurrent malignancy. * **C. Acute Laryngitis:** This is the most common cause of hoarseness *overall*, but it is a self-limiting condition typically lasting less than 1–2 weeks, often following a viral upper respiratory infection. * **D. Nodular Goitre:** While a large goitre can cause pressure symptoms, hoarseness in thyroid disease usually implies malignancy invading the recurrent laryngeal nerve, rather than a simple nodular goitre. **Clinical Pearls for NEET-PG:** * **Rule of 3 Weeks:** Any patient with hoarseness persisting beyond 3 weeks requires a mandatory indirect laryngoscopy (IDL) or fiberoptic laryngoscopy (FOL) to visualize the cords. * **Most common site of Laryngeal Cancer:** Glottis (vocal cords). * **Best Prognosis:** Glottic cancer (due to early presentation and sparse lymphatic drainage). * **Most common pathology:** Squamous Cell Carcinoma (SCC).

Q: Hoarseness with a typical barking cough and biphasic stridor are features of a lesion in which anatomical site?

Larynx. ### Explanation The clinical triad of **hoarseness**, **barking cough**, and **biphasic stridor** is the hallmark of subglottic inflammation, most commonly seen in **Croup (Laryngotracheobronchitis)**. 1. **Why Larynx is Correct:** * **Hoarseness:** Indicates involvement of the vocal cords (glottis). * **Barking Cough:** Result of subglottic edema and turbulent airflow through a narrowed larynx. * **Biphasic Stridor:** Stridor is typically inspiratory in supraglottic lesions and expiratory in tracheal lesions. However, lesions in the **glottis or subglottis** (parts of the larynx) result in **biphasic stridor** because the airway is narrowest here, causing turbulence during both phases of respiration. 2. **Why Other Options are Incorrect:** * **Hypopharynx/Pharynx:** Lesions here typically present with dysphagia, odynophagia, or a "muffled" (hot potato) voice rather than hoarseness. Stridor is rare unless the airway is secondary compressed. * **Trachea:** Tracheal lesions (like a foreign body or tracheomalacia) typically present with **expiratory stridor** or a "wheeze." Hoarseness is absent because the vocal cords are not involved. ### High-Yield Clinical Pearls for NEET-PG: * **Stridor Localization:** * **Inspiratory:** Supraglottic (e.g., Laryngomalacia, Epiglottitis). * **Biphasic:** Glottic/Subglottic (e.g., Croup, Subglottic stenosis). * **Expiratory:** Tracheal/Bronchial (e.g., Foreign body). * **Croup (Laryngotracheobronchitis):** Most common cause of stridor in children (6 months–3 years). Radiologically shows the **"Steeple Sign"** (subglottic narrowing) on AP view of the neck. * **Acute Epiglottitis:** Presents with drooling and a "Thumb sign" on lateral X-ray; hoarseness is usually absent.

Q: Bovine cough is characteristic of which of the following conditions?

Laryngeal paralysis. **Explanation:** **Bovine cough** is a characteristic clinical sign of **Recurrent Laryngeal Nerve (RLN) paralysis**, specifically when it is unilateral. **Why Laryngeal Paralysis is correct:** To produce an effective, explosive cough, the vocal cords must first adduct (close) tightly to build up subglottic pressure against a closed glottis. In RLN paralysis, the affected vocal cord remains in a paramedian or abducted position and cannot meet the midline. Consequently, the patient cannot build up subglottic pressure; when they attempt to cough, the air escapes through the glottic gap. This results in a **non-explosive, hollow, and low-pitched cough** that resembles the sound made by a cow (hence "bovine"). **Why other options are incorrect:** * **Acute Epiglottitis:** Characterized by a "muffled" or "hot potato" voice, severe odynophagia, and drooling. Cough is usually absent or minimal. * **Foreign Body Aspiration:** Typically presents with a sudden onset of choking, wheezing, and a "barking" or "croupy" cough if the object is in the trachea. * **Chronic Bronchitis:** Presents with a productive, "smoker’s" cough, usually worse in the morning, but the glottic closure mechanism remains intact, so the cough remains explosive. **High-Yield Clinical Pearls for NEET-PG:** * **Unilateral RLN Paralysis:** Most common cause is **surgical trauma** (e.g., thyroidectomy) or **malignancy** (e.g., apical lung cancer/Pancoast tumor). * **Left vs. Right:** The left RLN is more commonly paralyzed because of its longer intrathoracic course around the arch of the aorta. * **Voice Change:** In unilateral paralysis, the voice is typically **breathy** (weak) due to air escape. * **Bilateral RLN Paralysis:** Presents primarily with **stridor** and respiratory distress rather than bovine cough, as the airway is severely narrowed.

Q: Which are the blind areas of the larynx when visualized through video laryngoscopy?

Ventricle. The larynx contains several "hidden" or "blind" areas that are difficult to visualize completely using standard indirect laryngoscopy or fiberoptic video laryngoscopy. ### **Explanation of the Correct Answer** **A. Ventricle:** The laryngeal ventricle (Sinus of Morgagni) is a fusiform recess situated between the true vocal folds below and the false vocal folds (vestibular folds) above. Because it extends laterally and superiorly into the **saccule**, its interior depth cannot be visualized directly by looking down from above. It remains the most significant "blind spot" where early malignancies can remain occult. ### **Analysis of Incorrect Options** * **B. Subglottis:** While the subglottis is below the cords, it can often be partially visualized during deep inspiration when the cords abduct widely. It is considered a difficult area, but not a "blind" area in the same anatomical sense as the lateral recesses of the ventricle. * **C. Post-cricoid region:** This area lies behind the larynx (anterior wall of the hypopharynx). While it is a "hidden site" for malignancies, it is technically part of the **hypopharynx**, not the internal larynx. It can be visualized by maneuvers like the Valsalva or by tilting the scope. * **D. Lingual surface of epiglottis:** This is easily visualized as the scope passes over the base of the tongue into the vallecula. ### **High-Yield Clinical Pearls for NEET-PG** * **Hidden Sites of Larynx/Pharynx:** These include the **Ventricle**, **Subglottis**, **Post-cricoid space**, **Pyriform sinus apex**, and the **Posterior surface of the epiglottis**. * **Microlaryngoscopy (MLS):** This is the gold standard for evaluating these blind areas. To see the ventricle specifically, a probe is used to retract the false cords. * **Cancer Correlation:** Tumors arising in the ventricle (marginal tumors) often present late because they are shielded from view and do not cause early hoarseness.

Q: Kashima's operation is indicated for all the following conditions except:

Nasopharyngeal carcinoma. **Explanation:** **Kashima’s operation**, also known as **Posterior Laser Cordotomy**, is a surgical procedure primarily used to widen the glottic airway. It involves the laser excision of a wedge-shaped portion from the posterior part of one or both vocal cords (including the vocal process of the arytenoid). 1. **Why Nasopharyngeal Carcinoma (NPC) is the correct answer:** NPC is a malignancy of the nasopharynx, which is part of the upper pharynx, not the larynx. Its management primarily involves radiotherapy and chemotherapy. Kashima’s operation is a laryngeal procedure and has no role in the treatment of NPC. 2. **Analysis of incorrect options:** * **Bilateral Abductor Palsy:** This is the **classic indication** for Kashima’s operation. In this condition, the vocal cords remain in the midline, causing airway obstruction (stridor). Cordotomy creates a posterior glottic gap to improve breathing while preserving voice quality. * **Vocal Cord Dysplasia & Carcinoma of the Larynx:** While Kashima’s is most famous for palsy, CO2 lasers (used in the Kashima technique) are frequently employed for **endoscopic resection** of precancerous lesions (dysplasia) and early-stage laryngeal cancers (T1a glottic SCC) to achieve clear margins while preserving laryngeal function. **NEET-PG High-Yield Pearls:** * **Woodman’s Operation:** An alternative for bilateral abductor palsy involving an external approach (arytenoidectomy). * **Key Advantage of Kashima’s:** It is endoscopic, bloodless, and avoids a permanent tracheostomy. * **Complication:** The main risk is a breathy voice or aspiration if the excision is too large.

Q: What is the most common site for laryngeal cartilaginous tumors?

Cricoid cartilage. **Explanation:** Laryngeal cartilaginous tumors (Chondromas and Chondrosarcomas) are rare, accounting for less than 1% of all laryngeal neoplasms. **Why Cricoid Cartilage is the Correct Answer:** The **cricoid cartilage** is the most common site, involved in approximately **70-75%** of cases. Within the cricoid, the **posterior lamina** is the specific site of origin in the majority of patients. These tumors typically arise from the hyaline cartilage. Clinically, they present as a slow-growing endolaryngeal mass, often leading to progressive airway obstruction or dysphagia due to their posterior location. **Analysis of Incorrect Options:** * **B. Thyroid Cartilage:** This is the second most common site (approx. 15-20%). Tumors here usually present as a palpable, painless neck swelling. * **C. Arytenoid Cartilage:** Involvement is rare. When it occurs, it may present early with hoarseness due to vocal cord fixation. * **D. Corniculate Cartilage:** These are tiny accessory cartilages; primary tumors at this site are extremely rare and not clinically significant for exam purposes. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Chondroma is benign, but **Chondrosarcoma** is the most common mesenchymal malignancy of the larynx. * **Radiological Hallmark:** On CT scan, these tumors show a "popcorn" calcification pattern (stippled calcification). * **Treatment:** Conservative surgical excision (organ-preserving) is preferred over total laryngectomy because these tumors are slow-growing and rarely metastasize. * **Gender Predominance:** They are more common in males (3:1 ratio), typically in the 5th to 6th decades of life.

Q: Tubercular laryngitis primarily affects which part of the larynx?

Posterior commissure of larynx. ### Explanation **Correct Option: B. Posterior commissure of larynx** Laryngeal tuberculosis is almost always secondary to pulmonary tuberculosis. The infection reaches the larynx via **bronchogenic spread** (infected sputum). When a patient is in a recumbent or supine position, the infected sputum pools in the most dependent part of the larynx, which is the **posterior commissure** (interarytenoid area). The bacilli invade the mucosa, leading to the classic "mammillated" (pachydermia-like) appearance. The posterior part of the larynx is also highly vascular and has a high density of mucous glands, making it more susceptible to the inflammatory process of TB. **Analysis of Incorrect Options:** * **A. Anterior commissure:** This area is typically spared in tuberculosis but is a common site for the spread of laryngeal carcinoma and the formation of laryngeal webs. * **C. Anywhere within the larynx:** While TB can involve other structures (like the epiglottis or vocal cords), it has a distinct predilection for the posterior glottis. It is not a random distribution. * **D. Superior surface of larynx:** This is not a standard anatomical term used to describe the primary site of TB infection. The epiglottis (part of the superior larynx) is involved in the "lupoid" variety of TB, but the posterior commissure remains the most common site overall. **Clinical Pearls for NEET-PG:** * **Classic Appearance:** "Mouse-nibbled" ulcers on the vocal cords and a "Turban-shaped" epiglottis (due to edema). * **Symptoms:** Painful swallowing (**Odynophagia**) is a hallmark, often referred to the ear via the vagus nerve. * **Diagnosis:** Sputum for AFB is the most important initial test; Chest X-ray usually shows active pulmonary cavitation. * **Treatment:** Standard Anti-Tubercular Therapy (ATT). The laryngeal lesions usually heal rapidly once systemic treatment begins.

Question 1

What is the commonest cause of hoarseness of voice in an elderly man with a duration of more than 3 months?

Accepted Answer

Cancer of the larynx

Answer

Chronic bronchitis

Answer

Acute laryngitis

Answer

Nodular goitre

Question 2

Which of the following is FALSE regarding laryngeal papillomatosis?

Accepted Answer

If it leads to respiratory distress, tracheotomy is done as an immediate procedure.

Answer

It is due to HPV infection.

Answer

Microdebrider is used for excision.

Answer

It has a high recurrence rate.

Question 3

Hoarseness with a typical barking cough and biphasic stridor are features of a lesion in which anatomical site?

Accepted Answer

Larynx

Answer

Hypopharynx

Answer

Trachea

Answer

Pharynx

Question 4

Bovine cough is characteristic of which of the following conditions?

Accepted Answer

Laryngeal paralysis

Answer

Acute epiglottitis

Answer

Foreign body aspiration

Answer

Chronic bronchitis

Question 5

Which are the blind areas of the larynx when visualized through video laryngoscopy?

Accepted Answer

Ventricle

Answer

Subglottis

Answer

Post cricoid region

Answer

Lingual surface of epiglottis

Question 6

Kashima's operation is indicated for all the following conditions except:

Accepted Answer

Nasopharyngeal carcinoma

Answer

Vocal cord dysplasia

Answer

Carcinoma of the larynx

Answer

Bilateral abductor palsy

Question 7

What is the most common site for laryngeal cartilaginous tumors?

Accepted Answer

Cricoid cartilage

Answer

Thyroid cartilage

Answer

Arytenoid cartilage

Answer

Corniculate cartilage

Question 8

Tubercular laryngitis primarily affects which part of the larynx?

Accepted Answer

Posterior commissure of larynx

Answer

Anterior commissure

Answer

Anywhere within the larynx

Answer

Superior surface of larynx

Question 9

A 30-year-old female presented with stridor following an upper respiratory infection. Laryngoscopy shows a glottic gap of 3 mm. Which of the following is NOT a management option?

Accepted Answer

Type I thyroplasty

Answer

Tracheostomy

Answer

Type II thyroplasty

Answer

Cordectomy

Question 10

Injury of which nerve most commonly leads to vocal cord paralysis?

Accepted Answer

Recurrent laryngeal

Answer

External laryngeal

Answer

Internal laryngeal

Answer

Superior laryngeal

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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