Phoniatrics and Voice Disorders Practice Questions

Q: What is true regarding functional aphonia?

On laryngoscopy, vocal cords are abducted. **Functional Aphonia** (also known as Hysterical Aphonia) is a conversion disorder where a patient loses their voice despite having a normal laryngeal mechanism. It is most commonly seen in young females undergoing emotional stress. ### **Explanation of Options** * **Correct Answer (C):** On laryngoscopy, the vocal cords appear normal in structure and mobility. However, when the patient attempts to speak, the **vocal cords remain abducted** (open) and fail to meet in the midline. Interestingly, during "reflexive" actions like **coughing or throat clearing**, the vocal cords adduct perfectly, producing a sharp sound. This discrepancy is the hallmark of the diagnosis. * **Option A:** This is incorrect because functional aphonia has a significantly **higher incidence in females** than males. * **Option B:** There is **no organic paralysis**. The nerve supply (Recurrent Laryngeal Nerve) and the muscles are intact; the condition is purely psychological. * **Option D:** While speech therapy is used, the **treatment of choice is Psychological Counseling** and reassurance. Often, "persuasion" or "suggestion" therapy (convincing the patient they can speak) results in a dramatic recovery. ### **High-Yield Clinical Pearls for NEET-PG** * **The "Cough" Test:** A patient with functional aphonia can produce a loud, forceful cough (proving adductor function), whereas a patient with true vocal cord paralysis cannot. * **Voice Quality:** The patient usually speaks in a whisper. * **Laryngeal Appearance:** The cords often form a "V" shape on phonation (posterior gap) or remain completely abducted. * **Differential Diagnosis:** Must be distinguished from *Adductor Spasmodic Dysphonia*, where the cords adduct too tightly (strained-strangled voice).

Q: Under what conditions is endotracheal tube testing performed?

No anesthesia. ### Explanation The correct answer is **C. No anesthesia**. **Underlying Medical Concept:** Endotracheal tube (ETT) testing, specifically in the context of **Phoniatrics**, is used to assess the functional status of the vocal folds and the integrity of the recurrent laryngeal nerve (RLN). The primary goal is to observe the **voluntary and reflex movement** of the vocal folds. If any form of anesthesia (General or Local) is administered, the sensory-motor reflex arc is interrupted. To accurately evaluate the patient's ability to adduct/abduct the vocal folds or to perform a "cough test" to check for glottic competence, the patient must be fully conscious and have intact airway reflexes. **Why the other options are incorrect:** * **General Anesthesia (B):** This involves neuromuscular blockade or deep sedation, which causes vocal fold paralysis or immobility, making it impossible to assess active laryngeal function. * **Local Anesthesia (D):** Applying local anesthetics (like lignocaine spray) to the endolarynx abolishes the cough reflex and sensory feedback, which can mask underlying pathologies like sensory laryngeal neuropathy or aspiration risks. * **Ketamine (A):** While Ketamine preserves airway reflexes better than other induction agents, it still induces a dissociative state where voluntary commands (e.g., "say 'Eee'") cannot be followed. **High-Yield Clinical Pearls for NEET-PG:** * **Stroboscopy:** The gold standard for assessing the mucosal wave of vocal folds; also performed without general anesthesia. * **RLN Injury:** During thyroid surgery, if an ETT with electrodes is used for Nerve Monitoring (IONM), the patient is under GA, but **neuromuscular blockers must be avoided** after induction to allow for electromyographic (EMG) signals. * **Positioning:** For most phoniatric bedside tests, the patient is in a sitting position to mimic natural phonation.

Q: A female patient presents with a male-like voice. What type of thyroplasty is typically indicated?

Type IV. **Explanation:** The patient presents with **Androphonia** (a female with a male-like low pitch). Pitch is determined by the tension, length, and mass of the vocal folds. To raise the pitch, the vocal folds must be lengthened or tensed. **Type IV Thyroplasty (Cricothyroid Approximation)** is the procedure of choice. It involves suturing the thyroid cartilage to the cricoid cartilage, mimicking the action of the cricothyroid muscle. This increases the distance between the anterior commissure and the arytenoids, thereby **lengthening and tensing the vocal folds**, which raises the fundamental frequency (pitch). **Analysis of Incorrect Options:** * **Type I (Medialization):** Used for unilateral vocal cord palsy. It pushes the cord toward the midline to improve glottic closure. * **Type II (Lateralization):** Used for Adductor Spasmodic Dysphonia. It moves the cords apart to prevent forceful over-approximation. * **Type III (Relaxation/Shortening):** Used for **Puberphonia** (a male with a high-pitched female voice). It involves vertical strips of cartilage being removed to slacken the cords, thereby **lowering the pitch**. **NEET-PG High-Yield Pearls:** * **Isshiki Classification:** The standard classification for thyroplasty (Phonosurgery). * **Puberphonia:** Most common cause is psychological; initial treatment is **Gutzmann’s Pressure Test** (manual depression of the thyroid cartilage) and speech therapy. Surgery (Type III) is reserved for refractory cases. * **Androphonia:** Often seen in hormonal imbalances or post-virilization; Type IV thyroplasty is the surgical solution.

Q: What is the treatment of choice for nodules present at the junction of the anterior one-third and posterior two-thirds of the vocal cords in a 30-year-old female singer with a history of gastroesophageal reflux?

Speech therapy and Proton Pump Inhibitor (PPI). ### Explanation **1. Why Option C is Correct:** The clinical presentation describes **Vocal Nodules** (also known as Singer’s or Screamer’s nodules). These are benign, symmetrical, inflammatory thickenings located at the **junction of the anterior 1/3 and posterior 2/3** of the vocal cords—the point of maximum vibratory amplitude. The primary etiology is **vocal abuse** (common in singers), and **Gastroesophageal Reflux Disease (GERD)** is a significant aggravating factor that prevents healing. The first-line management for vocal nodules is always **conservative**. Speech therapy (voice rest and re-education) addresses the mechanical cause, while Proton Pump Inhibitors (PPIs) treat the chemical irritation from reflux. Surgery is reserved only for chronic, fibrotic nodules that fail conservative management. **2. Why Other Options are Incorrect:** * **Options A & B (Microlaryngectomy/CO2 Laser):** Surgical intervention is **not** the first-line treatment. Premature surgery can lead to vocal cord scarring, which is detrimental to a professional singer’s career. Surgery is only considered if there is no improvement after 3–6 months of speech therapy. * **Option D (Direct Laryngoscopy and Biopsy):** This is an invasive procedure used for suspicious, asymmetrical, or neoplastic lesions. Vocal nodules have a classic appearance and history; a biopsy is unnecessary and potentially harmful to the delicate mucosal wave of a singer. **3. Clinical Pearls for NEET-PG:** * **Location:** Junction of anterior 1/3 and posterior 2/3 (Site of maximum trauma). * **Demographics:** Most common in male children (Screamer’s nodules) and adult females (Singer’s nodules). * **Stroboscopy:** Shows symmetrical "hourglass" glottic closure. * **Histology:** Characterized by Reinke’s edema, fibrosis, and epithelial hyperplasia. * **Management Rule:** "Voice therapy first, surgery last."

Q: What is the term for a young man whose voice has not broken?

Puberphonia. **Explanation:** **Puberphonia (Mutational Falsetto)** is the correct answer. It refers to the failure of the male voice to change from the high-pitched prepubertal quality to the low-pitched adult male quality at puberty. * **Mechanism:** During puberty, the male larynx grows significantly under testosterone influence, and the vocal cords lengthen and thicken. In puberphonia, the patient (usually due to psychological reasons or habit) continues to use the prepubertal mechanism by keeping the vocal cords tense and the larynx elevated. * **Key Feature:** The voice is high-pitched, breathy, and unstable. It is often successfully treated with **Gutzmann’s pressure test** (manual downward pressure on the thyroid cartilage) and speech therapy. **Analysis of Incorrect Options:** * **Androphonia:** This is the opposite of puberphonia; it refers to a female possessing a low-pitched, masculine voice (often seen in Virilization or Reinke’s edema). * **Plica Ventricularis (Ventricular Dysphonia):** This occurs when the **false vocal cords** (ventricular bands) are used for phonation instead of the true vocal cords. It results in a rough, low-pitched, and strained voice. * **Functional Aphonia:** A psychological disorder (usually in young females) where the patient speaks only in a whisper despite having a normal larynx. On coughing, the vocal cords adduct normally, proving the mechanism is intact. **High-Yield Clinical Pearls for NEET-PG:** * **Gutzmann’s Test:** Diagnostic and therapeutic maneuver for Puberphonia. * **Type 3 Thyroplasty (Relaxation Thyroplasty):** Surgical management for puberphonia if speech therapy fails. * **Type 4 Thyroplasty (Tension Thyroplasty):** Used for Androphonia to raise the pitch.

Q: In thyroplasty type 2, what is the position of the vocal cord?

Lateralized. **Explanation:** Thyroplasty, also known as **Isshiki’s framework surgery**, involves altering the position or tension of the vocal cords by manipulating the thyroid cartilage. **Thyroplasty Type 2 (Lateralization)** is indicated for **Adductor Spasmodic Dysphonia**. In this condition, the vocal cords close too tightly, causing a "strangled" or "strained" voice. To correct this, a vertical midline incision is made in the thyroid cartilage, and the two halves are pulled apart (lateralized) and held in place with spacers (e.g., titanium bridges). This moves the vocal cords away from the midline, preventing them from slamming together and resulting in a smoother, more breathy voice. **Analysis of Incorrect Options:** * **B. Medialized (Type 1):** This is the most common type, used for **Unilateral Vocal Cord Palsy**. A window is created in the thyroid cartilage to push the paralyzed cord toward the midline to improve closure. * **C. Shortened (Type 3):** Also called **Relaxation Thyroplasty**, it involves removing a vertical strip of cartilage to shorten the cords, thereby **lowering the pitch** (used in Androphonia). * **D. Lengthened (Type 4):** Also called **Tension Thyroplasty**, it involves cricothyroid approximation to stretch the cords, thereby **raising the pitch** (used in Puberphonia). **High-Yield Clinical Pearls for NEET-PG:** * **Type 1:** Medialization (for Paralysis) – *Think: "1 is for One-sided palsy"* * **Type 2:** Lateralization (for Spasmodic Dysphonia) * **Type 3:** Relaxation (Lowers pitch) * **Type 4:** Stretching/Tension (Raises pitch) – *Think: "4 is for High pitch/Puberphonia"*

Q: Androphonia is treated by which type of thyroplasty?

Type 4 thyroplasty. **Explanation:** **Androphonia** is a condition where a female possesses an abnormally low-pitched, masculine voice. The physiological goal of treatment is to **increase the pitch** of the voice. Pitch is directly proportional to the tension and length of the vocal cords. **Why Type 4 is Correct:** **Type 4 Thyroplasty (Cricothyroid Approximation)** is designed to increase pitch. It involves suturing the thyroid cartilage to the cricoid cartilage, mimicking the action of the cricothyroid muscle. This maneuver stretches and increases the tension of the vocal folds, thereby raising the fundamental frequency of the voice. It is the gold standard surgical treatment for androphonia and gender-affirming voice surgery (trans-female). **Analysis of Incorrect Options:** * **Type 1 (Medialization):** Used for unilateral vocal cord palsy. It pushes the vocal cord toward the midline to improve glottic closure. * **Type 2 (Lateralization):** Used for Adductor Spasmodic Dysphonia. It moves the vocal cords apart to prevent forceful spasms. * **Type 3 (Relaxation):** Used for **Puberphonia** (high-pitched male voice). It involves shortening/relaxing the vocal cords to lower the pitch—the exact opposite of the requirement for androphonia. **High-Yield Clinical Pearls for NEET-PG:** * **Isshiki Classification:** The standard classification for thyroplasty (Phonosurgery). * **Puberphonia:** First-line treatment is **Gutzmann’s Pressure Test** (Voice therapy); if it fails, Type 3 Thyroplasty is performed. * **Androphonia:** Often caused by virilization (hormonal) or chronic smoking (Reinke’s edema). * **Mnemonic for Pitch:** Type **3** (Lowering/Relaxing) vs. Type **4** (Raising/Tension).

Q: Phonation in esophageal speech in a patient who has undergone laryngectomy is produced by which structure?

Pharyngo-esophageal segment. **Explanation:** In a patient who has undergone a total laryngectomy, the primary source of sound (the larynx) is removed. To regain speech, patients can learn **Esophageal Speech**. **Why the Pharyngo-esophageal (PE) segment is correct:** In esophageal speech, the patient swallows air into the upper esophagus and then expels it in a controlled manner. As the air is forced back up, it causes the mucosal folds of the **Pharyngo-esophageal (PE) segment** (primarily the **Cricopharyngeus muscle**) to vibrate. This vibration acts as the "new vocal cords" (neoglottis), producing a low-pitched sound that is then articulated into speech by the tongue and lips. **Analysis of Incorrect Options:** * **A. Buccal cavity:** While the mouth and buccal cavity are essential for *articulation* (forming words), they do not act as the vibratory source for phonation. * **B. Pharynx:** Although the PE segment is located at the junction of the pharynx and esophagus, the "pharynx" as a whole is too broad an anatomical term. The specific vibratory sphincter is the PE segment. * **C. Trachea:** In a total laryngectomy, the trachea is diverted to a permanent stoma in the neck. It is completely disconnected from the digestive tract/mouth; therefore, tracheal air cannot be used for esophageal speech. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Vibrator:** The Cricopharyngeus muscle is the most important component of the PE segment. * **Voice Quality:** Esophageal speech is low-pitched, hoarse, and has a short phrase length (limited by esophageal air capacity). * **Gold Standard:** While esophageal speech is an option, **Tracheo-esophageal Puncture (TEP)** with a prosthesis (e.g., Blom-Singer valve) is currently the most common and successful method of post-laryngectomy rehabilitation. * **Electrolarynx:** An external battery-operated device used by patients who cannot master esophageal or TEP speech.

Question 1

A Blom-Singer prosthesis is used:

Accepted Answer

To divert tracheal air into the esophagus for voice production in laryngeal patients

Answer

As a ventilation tube in otitis media with effusion

Answer

To close a perforation in the nasal septum

Answer

In stapedectomy to conduct sound from the incus to the oval window

Question 2

What is true regarding functional aphonia?

Accepted Answer

On laryngoscopy, vocal cords are abducted

Answer

Higher incidence in males

Answer

Due to vocal cord paralysis

Answer

Speech therapy is the treatment of choice

Question 3

A 20-year-old male presents with throat pain and easy fatigability of his voice. Indirect laryngeal examination revealed both cords approximately well but leaving a triangular gap in the interarytenoid. What is your diagnosis?

Accepted Answer

Phonasthenia

Answer

Mutational falsetto voice

Answer

Functional aphonia

Answer

Ventricular dysphonia

Question 4

Under what conditions is endotracheal tube testing performed?

Accepted Answer

No anesthesia

Answer

Ketamine

Answer

General anesthesia

Answer

Local anesthesia

Question 5

A female patient presents with a male-like voice. What type of thyroplasty is typically indicated?

Accepted Answer

Type IV

Answer

Type I

Answer

Type II

Answer

Type III

Question 6

What is the treatment of choice for nodules present at the junction of the anterior one-third and posterior two-thirds of the vocal cords in a 30-year-old female singer with a history of gastroesophageal reflux?

Accepted Answer

Speech therapy and Proton Pump Inhibitor (PPI)

Answer

Microlaryngectomy

Answer

Microlaryngoscopic surgery with CO2 laser

Answer

Direct laryngoscopy and biopsy

Question 7

What is the term for a young man whose voice has not broken?

Accepted Answer

Puberphonia

Answer

Androphonia

Answer

Plica ventricularis

Answer

Functional aphonia

Question 8

In thyroplasty type 2, what is the position of the vocal cord?

Accepted Answer

Lateralized

Answer

Medialized

Answer

Shortened

Answer

Lengthened

Question 9

Androphonia is treated by which type of thyroplasty?

Accepted Answer

Type 4 thyroplasty

Answer

Type 1 thyroplasty

Answer

Type 2 thyroplasty

Answer

Type 3 thyroplasty

Question 10

Phonation in esophageal speech in a patient who has undergone laryngectomy is produced by which structure?

Accepted Answer

Pharyngo-esophageal segment

Answer

Buccal cavity

Answer

Pharynx

Answer

Trachea

Phoniatrics and Voice Disorders — MCQs

Phoniatrics and Voice Disorders — MCQs

On this page

Practice by Chapter

Want unlimited practice?