Diseases of the Larynx Practice Questions

Q: Reinke's edema is typically seen in which part of the larynx?

Edges of vocal cords. **Explanation:** **Reinke’s Edema** is a clinical condition characterized by the accumulation of gelatinous fluid in the **Reinke’s space**. This space is a potential subepithelial space located between the vocal ligament and the overlying squamous epithelium of the **true vocal cords**. 1. **Why Option A is Correct:** The Reinke’s space is anatomically restricted to the **edges of the vocal cords**. It lacks lymphatic drainage, which predisposes it to fluid accumulation when subjected to chronic irritation (most commonly **smoking** and **vocal abuse**). This results in a "baggy," polypoid appearance of the vocal folds. 2. **Why Other Options are Incorrect:** * **Vestibular folds (False Cords):** These are located superior to the true vocal cords and do not contain Reinke’s space; they are rarely involved in localized edema of this nature. * **Between true and false vocal cords:** This area is the **Laryngeal Ventricle (Sinus of Morgagni)**. While pathologies like laryngoceles occur here, Reinke’s edema is specific to the cord margins. * **Pyriform fossa:** This is a part of the **hypopharynx**, not the larynx. It is a common site for foreign bodies and malignancies, but not Reinke’s edema. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Strongly associated with **heavy smoking** and chronic voice strain. * **Clinical Presentation:** Typically presents as a **low-pitched, hoarse voice** (often described as a "manly voice" in females). * **Treatment:** Smoking cessation is mandatory. Definitive treatment involves **decortication** of the vocal cord (stripping the mucosa) using a "microflap" technique. * **Histology:** Shows loose stroma, edema, and dilated capillaries.

Q: Bilateral recurrent laryngeal nerve palsy is most commonly associated with which of the following conditions?

Thyroid surgery. **Explanation:** The **Recurrent Laryngeal Nerve (RLN)** is the most common nerve injured during neck surgeries due to its intimate anatomical relationship with the inferior thyroid artery and the posterior capsule of the thyroid gland. **1. Why Thyroid Surgery is Correct:** Thyroidectomy (especially total thyroidectomy) is the leading cause of **bilateral** RLN palsy. During the procedure, the nerves can be damaged via transection, clamping, traction, or thermal injury. While unilateral injury is more frequent, bilateral injury is a dreaded complication that often results in the vocal cords assuming a median or paramedian position, leading to acute airway obstruction and necessitating an emergency tracheostomy. **2. Analysis of Incorrect Options:** * **Bronchogenic Carcinoma:** This is the most common cause of **unilateral** left-sided RLN palsy. The left RLN loops around the arch of the aorta and is susceptible to compression by mediastinal lymph nodes or apical lung tumors (Pancoast tumor). It rarely presents bilaterally. * **Carcinoma of the Esophagus:** While esophageal malignancies can involve the RLN (more commonly the left), they typically present with unilateral involvement and are less common causes than surgical trauma. * **Neck Trauma:** Penetrating or blunt neck trauma can injure the RLN, but such injuries are usually focal and unilateral. **Clinical Pearls for NEET-PG:** * **Most common cause of Unilateral RLN palsy:** Malignancy (specifically Bronchogenic Carcinoma). * **Most common cause of Bilateral RLN palsy:** Surgical trauma (Thyroidectomy). * **Position of cords:** In bilateral complete palsy, cords lie in the **median/paramedian** position (adducted), causing inspiratory stridor but a relatively preserved voice. * **Semon’s Law:** States that in progressive lesions of the RLN, the abductor fibers (posterior cricoarytenoid) are injured before the adductor fibers.

Q: A chronic smoker with a history of hoarseness of voice is found to have fixation of the vocal cords on examination. What is the most likely treatment he will require?

Subtotal laryngectomy. **Explanation:** The clinical presentation of a chronic smoker with hoarseness and **fixation of the vocal cords** is a hallmark sign of **Stage T3 Glottic Carcinoma**. In laryngeal cancer, vocal cord fixation indicates that the tumor has invaded deep structures such as the thyroarytenoid muscle, the cricoarytenoid joint, or the paraglottic space. 1. **Why Subtotal Laryngectomy is correct:** For T3 lesions (fixed cord), the standard of care involves aggressive management. While total laryngectomy was traditionally the gold standard, **Subtotal Laryngectomy** (specifically Supracricoid Laryngectomy) is an organ-preserving surgical option that allows for the removal of the tumor while maintaining physiological speech and swallowing without a permanent stoma. 2. **Why other options are incorrect:** * **Stripping of the vocal cord:** This is used for benign lesions (like Reinke’s edema) or Carcinoma-in-situ (Tis). It is inadequate for invasive cancer with cord fixation. * **Radiotherapy:** While RT can be used for T3 lesions in some protocols, surgery (Subtotal or Total Laryngectomy) is often preferred for advanced local disease with cord fixation to ensure clear margins, especially if the patient is a heavy smoker with a high risk of recurrence. * **Laser cordectomy:** This is indicated for early-stage lesions (T1a) where the cord is still mobile. It cannot address deep infiltration causing fixation. **Clinical Pearls for NEET-PG:** * **T1:** Tumor limited to vocal cord(s); normal mobility. * **T2:** Tumor extends to supraglottis/subglottis; **impaired** mobility. * **T3:** Tumor limited to larynx with **vocal cord fixation**. * **T4:** Invasion through thyroid cartilage or into extrinsic tissues. * **Most common site** of laryngeal cancer: Glottis. * **Most common pathology:** Squamous Cell Carcinoma.

Q: What is the T stage for carcinoma of the epiglottis involving the pre-epiglottic space?

T3 stage. **Explanation:** The staging of Supraglottic Laryngeal Carcinoma (which includes the epiglottis) is determined by the extent of local invasion and vocal cord mobility. **Why T3 is the correct answer:** According to the AJCC (8th Edition) TNM staging for the supraglottis, a tumor is classified as **T3** if it is limited to the larynx but involves any of the following: 1. **Invasion of the pre-epiglottic space.** 2. Invasion of the paraglottic space. 3. Fixation of the vocal cords. 4. Inner cortex of the thyroid cartilage invasion. The pre-epiglottic space is a fat-filled potential space located anterior to the epiglottis; its involvement signifies deeper infiltration, upgrading the stage to T3. **Why other options are incorrect:** * **T1:** The tumor is limited to one subsite of the supraglottis (e.g., lingual surface of the epiglottis) with normal vocal cord mobility. * **T2:** The tumor invades more than one adjacent subsite of the supraglottis or glottis, or a region outside the supraglottis (e.g., mucosa of the base of tongue), without fixation of the larynx. * **T4:** This represents advanced disease. **T4a** involves invasion through the outer cortex of the thyroid cartilage or into soft tissues of the neck (thyroid, esophagus). **T4b** involves the prevertebral space or encasement of the carotid artery. **High-Yield Clinical Pearls for NEET-PG:** * **Pre-epiglottic space:** Bound by the hyoid bone (superiorly), thyroid cartilage/thyrohyoid membrane (anteriorly), and epiglottis (posteriorly). * **Hyo-epiglottic ligament:** Forms the "roof" of the pre-epiglottic space. * **Most common site** of Supraglottic CA: Epiglottis. * **Lymphatic spread:** Supraglottic tumors have a rich lymphatic network; hence, bilateral neck node involvement is common compared to glottic tumors.

Q: Which of the following procedures is NOT done in bilateral abductor palsy of vocal cords?

Teflon paste injection. **Explanation:** In **Bilateral Abductor Palsy**, the vocal cords are paralyzed in the midline or paramedian position. This results in a compromised airway (stridor) but a relatively preserved voice. The primary goal of management is to **widen the glottic chink** to improve breathing. **Why Teflon Paste Injection is the Correct Answer:** Teflon paste injection is a **medialization procedure**. It is used to add bulk to a vocal cord that is paralyzed in the lateral position (Unilateral Vocal Cord Palsy) to improve glottic closure and voice quality. In bilateral abductor palsy, the cords are already at the midline; injecting Teflon would further narrow the airway, potentially causing total obstruction. Therefore, it is contraindicated. **Analysis of Other Options:** * **Cordectomy:** Involves the surgical removal of a portion of the vocal cord (usually the posterior part) to create a larger airway space. * **Arytenoidectomy:** Removal of the arytenoid cartilage (e.g., Woodman’s procedure) to widen the posterior glottis. This is a classic surgical treatment for bilateral abductor palsy. * **Nerve Muscle Implant:** A reinnervation technique (e.g., using the omohyoid muscle and ansa cervicalis) aimed at restoring the function of the posterior cricoarytenoid muscle (the only abductor). **Clinical Pearls for NEET-PG:** * **Most common cause** of bilateral abductor palsy: Thyroid surgery (injury to bilateral Recurrent Laryngeal Nerves). * **Treatment Priority:** Airway first (Tracheostomy if acute), followed by permanent widening procedures (Lateralization). * **Trade-off:** Any procedure that improves the airway in these patients (by lateralizing the cords) will inevitably worsen the quality of the voice.

Q: Which of the following statements about external laryngocele is FALSE?

Herniates through the cricothyroid membrane.. ### Explanation A **laryngocele** is an abnormal cystic dilatation of the saccule of the laryngeal ventricle, filled with air. Understanding its anatomy is key to identifying the correct answer. **Why Option D is the Correct (False) Statement:** An external laryngocele extends superiorly and exits the larynx by piercing the **thyrohyoid membrane**, specifically at the point where the superior laryngeal vessels and internal laryngeal nerve enter. It does **not** herniate through the cricothyroid membrane. The cricothyroid membrane is located lower in the larynx and is not the anatomical route for saccular herniation. **Analysis of Other Options:** * **Option A:** Because the laryngocele is air-filled and communicates with the airway, any increase in intralaryngeal pressure (like the **Valsalva maneuver**) causes the neck swelling to enlarge and become more prominent. This is a classic clinical sign (Bryce’s sign). * **Option B:** All laryngoceles originate from the **saccule of the laryngeal ventricle**. In an external laryngocele, the neck swelling maintains this communication via a stalk. * **Option C:** **CT scan** is the gold standard for diagnosis. It shows a well-defined, air-filled (or fluid-filled if infected) sac. It helps differentiate it from other neck masses like branchial cysts. **High-Yield Clinical Pearls for NEET-PG:** * **Types:** Internal (confined to endolarynx), External (pierces thyrohyoid membrane), and Combined (most common). * **Risk Factors:** Activities that increase intralaryngeal pressure (e.g., trumpet players, glass blowers) or obstructing laryngeal tumors (always perform direct laryngoscopy to rule out **squamous cell carcinoma** at the neck of the saccule). * **Laryngopyocele:** When a laryngocele becomes infected and filled with pus. * **Bryce’s Sign:** Gurgling sound heard on compression of the neck swelling.

Q: All of the following spaces are seen in relation to the larynx except?

Space of Gillette. ### Explanation The correct answer is **D. Space of Gillette**, as it is a retropharyngeal space, not a laryngeal space. #### 1. Why "Space of Gillette" is the correct answer: The **Space of Gillette** (also known as the **Retropharyngeal Space**) is a potential space located behind the pharynx, bounded anteriorly by the buccopharyngeal fascia and posteriorly by the prevertebral fascia. It contains the Nodes of Rouviere. Clinically, it is significant as a site for retropharyngeal abscesses, particularly in children, but it is anatomically distinct from the internal structure of the larynx. #### 2. Analysis of Incorrect Options (Laryngeal Spaces): * **Space of Boyer (Pre-epiglottic Space):** This is a wedge-shaped space located anterior to the epiglottis. It is bounded by the thyroid cartilage and thyrohyoid membrane anteriorly, and the epiglottis posteriorly. It is a common route for the spread of supraglottic tumors. * **Space of Tucker (Paraglottic Space):** This is a potential space lateral to the endolarynx. It is bounded by the thyroid cartilage laterally and the conus elasticus/quadrangular membrane medially. It allows for the transglottic spread of laryngeal cancer. * **Reinke’s Space:** This is a potential space in the lamina propria of the vocal folds, located between the vocal ligament and the overlying epithelium. Accumulation of fluid here leads to **Reinke’s Edema**, often seen in chronic smokers. #### 3. High-Yield Clinical Pearls for NEET-PG: * **Transglottic Spread:** Laryngeal cancers often cross the ventricle to involve both supraglottis and glottis by invading the **Paraglottic space (Tucker's)**. * **Hyo-epiglottic Ligament:** This forms the "roof" of the pre-epiglottic space. * **Reinke’s Edema:** Characterized by a "low-pitched, gravelly voice" and is typically treated with smoking cessation and microlaryngeal surgery (decortication).

Q: An infant after birth is noticed to have stridor and a hoarse cry. All of the following diagnoses are possible except:

Laryngomalacia. **Explanation:** The key to solving this question lies in differentiating between the clinical presentations of various causes of congenital stridor. **Why Laryngomalacia is the correct answer:** Laryngomalacia is the most common cause of congenital stridor. However, its hallmark feature is a **normal, clear cry**. The pathology involves supraglottic collapse (floppy aryepiglottic folds or omega-shaped epiglottis) during inspiration, which does not affect the vocal cords themselves. Therefore, while it causes inspiratory stridor that worsens with crying or supine positioning, the voice/cry remains unaffected. **Analysis of Incorrect Options:** * **Laryngeal Web:** These are most commonly glottic (75%). Because they involve the vocal folds, they characteristically present with both stridor and a **hoarse cry** or even aphonia from birth. * **Laryngeal Paralysis:** Congenital vocal cord paralysis (often bilateral) presents immediately at birth with significant respiratory distress and a **weak or hoarse cry** due to the inability of the cords to adduct/abduct properly. * **Congenital Laryngeal Cyst:** Large saccular cysts can displace the endolarynx and interfere with vocal cord vibration or glottic patency, leading to both stridor and **muffled or hoarse phonation**. **NEET-PG Clinical Pearls:** * **Laryngomalacia:** Most common cause of stridor in neonates; stridor is **inspiratory** and improves in the **prone** position. * **Hoarseness in an infant:** Always points toward a pathology involving the **glottis** (vocal cords). * **Laryngeal Web:** Associated with **DiGeorge Syndrome** (22q11 deletion). * **Subglottic Stenosis:** Most common cause of congenital stridor requiring tracheostomy; cry is usually normal, but stridor is **biphasic**.

Question 1

What is the treatment of choice for recurrent respiratory papillomatosis?

Accepted Answer

Laser ablation

Answer

Diathermy excision

Answer

Excision with microdebrider

Answer

Wait for spontaneous resolution

Question 2

A patient with which of the following is a candidate for a supraglottic laryngectomy?

Accepted Answer

A lesion of the laryngeal surface of the epiglottis below the hyoid bone with evidence of preepiglottic space invasion on computed tomography

Answer

A T2 lesion of the right aryepiglottic fold, a right false vocal cord, and impaired mobility of the true vocal cord

Answer

A lesion of the epiglottis, vallecula, and 1-cm, unilateral extension to the tongue base

Answer

An invasive lesion of the false vocal cord that is found to extend significantly into the ventricle at the time of surgical endoscopy

Question 3

Reinke's edema is typically seen in which part of the larynx?

Accepted Answer

Edges of vocal cords

Answer

Vestibular folds

Answer

Between true and false vocal cords

Answer

Pyriform fossa

Question 4

Bilateral recurrent laryngeal nerve palsy is most commonly associated with which of the following conditions?

Accepted Answer

Thyroid surgery

Answer

Neck trauma

Answer

Bronchogenic carcinoma

Answer

Carcinoma of the esophagus

Question 5

A chronic smoker with a history of hoarseness of voice is found to have fixation of the vocal cords on examination. What is the most likely treatment he will require?

Accepted Answer

Subtotal laryngectomy

Answer

Stripping of the vocal cord

Answer

Radiotherapy

Answer

Laser cordectomy

Question 6

What is the T stage for carcinoma of the epiglottis involving the pre-epiglottic space?

Accepted Answer

T3 stage

Answer

T2 stage

Answer

T1 stage

Answer

T4 stage

Question 7

Which of the following procedures is NOT done in bilateral abductor palsy of vocal cords?

Accepted Answer

Teflon paste injection

Answer

Cordectomy

Answer

Nerve muscle implant

Answer

Arytenoidectomy

Question 8

Which of the following statements about external laryngocele is FALSE?

Accepted Answer

Herniates through the cricothyroid membrane.

Answer

Produces a swelling in the neck on Valsalva maneuver.

Answer

Communicates with the laryngeal ventricle.

Answer

Can be identified on CT scan.

Question 9

All of the following spaces are seen in relation to the larynx except?

Accepted Answer

Space of Gillette

Answer

Space of Boyer

Answer

Space of Trucker

Answer

Reinke's space

Question 10

An infant after birth is noticed to have stridor and a hoarse cry. All of the following diagnoses are possible except:

Accepted Answer

Laryngomalacia

Answer

Laryngeal web

Answer

Laryngeal paralysis

Answer

Congenital laryngeal cyst

Diseases of the Larynx — MCQs

Diseases of the Larynx — MCQs

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