Category: Quiz

Ethmoidal Polyp

Ethmoidal Polyp

Q. 1

Which is not a feature of ethmoidal polyp?

 A

Cause nasal obstruction

 B

Cause loss of taste

 C

Are associated with cystic fibrosis

 D

Rhinorrhea is absent

Q. 1

Which is not a feature of ethmoidal polyp?

 A

Cause nasal obstruction

 B

Cause loss of taste

 C

Are associated with cystic fibrosis

 D

Rhinorrhea is absent

Ans. D

Explanation:

Q. 2

An old patient presented with bilateral nasal blockage since few weeks. He is a history of asthma and alleries. On examination, smooth, glistening, grape-like masses which are pale in color are seen.

 
Assertion: Only antrochoanal polyps should be subjected to histology.
 
Reason: Simple nasal polyp may masquerade a malignancy underneath.
 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Q. 2

An old patient presented with bilateral nasal blockage since few weeks. He is a history of asthma and alleries. On examination, smooth, glistening, grape-like masses which are pale in color are seen.

 
Assertion: Only antrochoanal polyps should be subjected to histology.
 
Reason: Simple nasal polyp may masquerade a malignancy underneath.
 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Ans. D

Explanation:

All polypi should be subjected to histology.

Simple nasal polyp may mask a malignancy underneath.

If a polypus is red and fleshy, friable and has granular surface, especially in older patients, think of malignancy.


Q. 3

Which of the following statements is NOT correct for ethmoidal polyp?

 A

Allergy is an etiological factor

 B

Occurs in the first decade of life

 C

Are bilateral

 D

Are often associated with bronchial asthma

Q. 3

Which of the following statements is NOT correct for ethmoidal polyp?

 A

Allergy is an etiological factor

 B

Occurs in the first decade of life

 C

Are bilateral

 D

Are often associated with bronchial asthma

Ans. B

Explanation:

Ethmoidal polyp is a bilateral condition which typically occur in middle aged individuals and not in the first decade of life. 

 
Difference between antrochoanal and ethmoid polyp:
 
 
Antrochoanal polyp
Ethmoid polyp
Age
Common in children Common in adults
Etiology
Usually infection Allergy or multifactorial
Number
Solitary Multiple
Side
Unilateral Bilateral
Origin
Maxillary sinus Ethmoid sinus
Growth
Grows towards the posterior choana Grows towards anterior nares
Lobes
Two or three Multiple small and grape like masses
Obstruction
Unilateral  Bilateral
Treatment
Usually surgical  Usually medical

Q. 4

Which of the following statements is not correct for Ethmoidal polyp:

 A

Allergy is an etiological factor

 B

Occur in the first decade of life

 C

Are bilateral

 D

Are often associated with bronchial asthma

Q. 4

Which of the following statements is not correct for Ethmoidal polyp:

 A

Allergy is an etiological factor

 B

Occur in the first decade of life

 C

Are bilateral

 D

Are often associated with bronchial asthma

Ans. B

Explanation:

Q. 5

Regarding ethmoidal polyp, which one of the following is true:

 A

Epistaxis

 B

Unilateral

 C

seen in children

 D

Associated with bronchial asthma

Q. 5

Regarding ethmoidal polyp, which one of the following is true:

 A

Epistaxis

 B

Unilateral

 C

seen in children

 D

Associated with bronchial asthma

Ans. D

Explanation:

Q. 6

Recurrent polyps are seen in:

 A

Antrochoanal polyp

 B

Ethmoidal polyp

 C

Nasal polyp

 D

Hypertrophic turbinate

Q. 6

Recurrent polyps are seen in:

 A

Antrochoanal polyp

 B

Ethmoidal polyp

 C

Nasal polyp

 D

Hypertrophic turbinate

Ans. B

Explanation:

 

Ethmoidal Polyps

  • They are mostly seen in adults.
  • Etiology—usual cause of ethmoidal polyps is allergy

Allergic nasal polyps are rarely, if ever seen in childhood. They are only seen in childhood in association with mucoviscoidosis.                                                                                                                                         

  • Ethmoidal polyps are also associated with:

Bronchial asthma

Aspirin intolerance

Cystic fibrosis

Nasal mastocystosis

– Syndromes like: Kartageners/Young syndrome/Churg-Strauss syndrome

  • It is generally bilateral
  • Appear as multiple, sessile or pedunculated masses like a bunch of grapes
  • Insensitive to touch and do not bleed on probing.
  • Recurrence is common after removal.

Q. 7

In a patient with multiple bilateral nasal polyps,  X-ray shows opacity in the paranasal sinuses. The treat­ment consists of all of the following except: 

 A

Epinephrine

 B

Corticosteroids

 C

Amphotericin B

 D

Antihistamines

Q. 7

In a patient with multiple bilateral nasal polyps,  X-ray shows opacity in the paranasal sinuses. The treat­ment consists of all of the following except: 

 A

Epinephrine

 B

Corticosteroids

 C

Amphotericin B

 D

Antihistamines

Ans. C

Explanation:

 

  • This patient is having ethmoidal polyp (because polyps are multiple and bilateral)
  • Main etiology of polyps is allergy.
  • Medical treatment of polyps is the same as that for allergic rhinitis which consists of:

Antihistaminics

Steroids—helpful in patients who cannot tolerate antihistamine or have asthma along with polyps. It is also useful to prevent recurrence after surgery

Decongestants such as epinephrine, phenylephrine, xylometazoline, etc.

  • Antifungals (e.g. Amphotericin B) have no role in treatment of polyps.



Q. 8

Patient with ethmoidal polyp undergoes polypectomy. Presents 6 months later with ethmoidal polyp. Correct Rx:

 A

Intranasal ethmoidectomy 

 B

Extranasal ethmoidectomy

 C

Caldwell-Luc procedure 

 D

Polypectomy

Q. 8

Patient with ethmoidal polyp undergoes polypectomy. Presents 6 months later with ethmoidal polyp. Correct Rx:

 A

Intranasal ethmoidectomy 

 B

Extranasal ethmoidectomy

 C

Caldwell-Luc procedure 

 D

Polypectomy

Ans. B

Explanation:

 

Treatment of ethmoidal polyp

  • Simple polypectomy: When there are one or two pedunculated polyps.
  • Intranasal ethmoidectomy: Indicated when polyps are multiple and sessile.
  • Extranasal ethmoidectomy: This is indicated when polyps recur after intranasal procedures.
  • Transantral ethmoidectomy: Indicated when infection and polypoidal changes are also seen in the maxillary antrum. In this case antrum is opened by Caldwell-Luc approach and the ethmoidal air cells approached through the medial wall of the antrum.
  • These days, ethmoidal polypi are removed by endoscopic sinus surgery (FESS) which is the TOC.

Q. 9

“Bernoulli’s theorem” explains:

 A

Nasal polyp

 B

Thyroglossal cyst

 C

Zenker’s diverticulum

 D

Laryngomalacia

Q. 9

“Bernoulli’s theorem” explains:

 A

Nasal polyp

 B

Thyroglossal cyst

 C

Zenker’s diverticulum

 D

Laryngomalacia

Ans. A

Explanation:

 

Bernoulli’s theorem states that if the speed of a fluid element increases as it travels along a horizontal streamline, the fresher of the fluid must decrease and conversely.                               —Fundamental of Physics, Halliday Resnic 6th/ed

Nasal polyps follow Bernoulli’s theorem as The increased speed of the air flowing through the nose decreases the pressure in the nasal cavity (Bernoulli’s theorem) which pulls down the polyp.



Q. 10

Multiple nasal polyp in children should guide the clini­cian to search for underlying:

 A

Mucoviscidosis

 B

Celiac disease

 C

Hirschsprung’s disease

 D

Sturge weber syndrome

Q. 10

Multiple nasal polyp in children should guide the clini­cian to search for underlying:

 A

Mucoviscidosis

 B

Celiac disease

 C

Hirschsprung’s disease

 D

Sturge weber syndrome

Ans. A

Explanation:

Q. 11

Most common nasal mass:

 A

Polyp

 B

Papilloma

 C

Angiofibroma

 D

None

Q. 11

Most common nasal mass:

 A

Polyp

 B

Papilloma

 C

Angiofibroma

 D

None

Ans. A

Explanation:

Q. 12

All of the following statements about intrinsic allergic Asthma are true, Except:

 A

Nasal polyp

 B

Normal IgE

 C

Family history Positive

 D

More aggressive

Q. 12

All of the following statements about intrinsic allergic Asthma are true, Except:

 A

Nasal polyp

 B

Normal IgE

 C

Family history Positive

 D

More aggressive

Ans. C

Explanation:

Answer is C (Family history +ve)

Intrinsic Asthma by defination is not allergic in nature and is not associated with a positive family history of allergy

Features of Intrinsic Asthma

(Nonatopic asthma- Approximately 10% of asthmatic patients are intrinsic)

  • Negative Family History of allergy
  • Negative skin test to common inhalant allergens (Not primarily caused by allergy)
  • Normal serum concentration of IgE.
  • Concomitant nasal polyps (Common)
  • Sensitivity to aspirin and related chemicals
  • Later onset of disease (adult-onset asthma)
  • More servere, persistent disease/asthma.

Q. 13

Aspirin-sensitive asthma is associated with:

 A

Obesity

 B

Urticaria

 C

Nasal polyp

 D

Extrinsic asthma

Q. 13

Aspirin-sensitive asthma is associated with:

 A

Obesity

 B

Urticaria

 C

Nasal polyp

 D

Extrinsic asthma

Ans. C

Explanation:

Answer is C (Nasal polyp):

`Aspirin associated Asthma usually begins with perennial vasomotor rhinitis that is followed by a hyperplastic rhinosinusitis with nasal polyps’ — Harrisons

Aspirin associated Asthma:

  • Primarily affects adults, although the condition may occur in childhood.
  • Usually begins with perennial vasomotor rhinitis that is followed by hyperplastic rhinosinusitis with nasal polyps.
  • Progressive asthma then appears.
  • On exposure to even very small quantities of aspirin affected individual typically develop ocular and nasal congestion and acute, often severe episodes of airways obstruction.
  • Death may follow ingestion of aspirin.

Q. 14

Which of the following statement is not correct about Ethmoidal polyp?

 A

Allergy is an etiological factor

 B

Occur in the first decade of life

 C

Are bilateral

 D

Are often associated with bronchial asthma

Q. 14

Which of the following statement is not correct about Ethmoidal polyp?

 A

Allergy is an etiological factor

 B

Occur in the first decade of life

 C

Are bilateral

 D

Are often associated with bronchial asthma

Ans. B

Explanation:

 

Ethmoidal polyps are multiple bilateral polyps arise from the numerous ethmoidal sinuses.

Ethmoidal polyps mostly occur in adult age, However any age group can be affected.

Nasal polypi are mostly seen in cases of allergic rhinitis and therefore ethmoidal polyps are considered of allergic origin.

There are various diseases associated with polyp formation :- chronic rhinosinusitis, asthma, cystic fibrosis, kartagener’s syndrome, young’s syndrome, churg – strauss syndrome, nasal mastocytosis, aspirin intolerance.



Voice Disorders

Voice Disorders

Q. 1

Rhinolalia clausa is associated with all of the following, EXCEPT:

 A

Allergic rhinitis

 B

Palatal paralysis

 C

Adenoids

 D

Nasal polyps

Q. 1

Rhinolalia clausa is associated with all of the following, EXCEPT:

 A

Allergic rhinitis

 B

Palatal paralysis

 C

Adenoids

 D

Nasal polyps

Ans. B

Explanation:

Palatal paralysis is a cause of Rhinolalia Aperta (Hypernasality) and not Rhinolilia Clausa (Hyponasality).
 
Rhinolalia Aperta (Hypernasality or hyperrhinolalia or open nasality) is defined as excess resonance of vowels and voiced consonants within the nasal cavities. The anatomic-physiologic basis is open coupling between the oral and nasal cavities due to incomplete closure of the hard palate and/or velopharyngeal sphincter.
 

Q. 2

In dysphonia plica ventricularis, sound is produced by 

 A

False vocal cords

 B

True vocal cords

 C

Ventricle of larynx

 D

Tongue

Q. 2

In dysphonia plica ventricularis, sound is produced by 

 A

False vocal cords

 B

True vocal cords

 C

Ventricle of larynx

 D

Tongue

Ans. A

Explanation:

 

In dysphonia plica ventricularis voice is produced by false vocal cords (ventricular folds).



Q. 3

Features of functional aphonia:

 A

Incidence in males

 B

Due to vocal cord paralysis

 C

Can cough

 D

a and b

Q. 3

Features of functional aphonia:

 A

Incidence in males

 B

Due to vocal cord paralysis

 C

Can cough

 D

a and b

Ans. C

Explanation:

 

  • Functional aphonia or hysterical aphonia is a functional disorder mostly seen in emotionally labile females in the age group of 15-30 years.
  • Laryngoscopy Examination shows vocal cord in abducted position and fails to adduct on phonation, however adduction is seen on coughing, indicating normal adductor function.

Treatment :  

Reassurance of the patient of normal laryngeal function and psychotherapy.

Speech therapy has no role in it.


Q. 4

Habitual dysphonia is characterized by:

 A

Poor voice in normal environment

 B

Related to stressful events

 C

Treatment is vocal exercise and reassurance

 D

a and c

Q. 4

Habitual dysphonia is characterized by:

 A

Poor voice in normal environment

 B

Related to stressful events

 C

Treatment is vocal exercise and reassurance

 D

a and c

Ans. D

Explanation:

 

When a person always uses a poor voice in normal circumstances, is called habitual dysphonia.

It is not related to stressful events and seems to be a habit.



Q. 5

Rhinolalia clausa is associated with all of the following except:

 A

Allergic rhinitis

 B

Palatal paralysis

 C

Adenoids

 D

Nasal polyps

Q. 5

Rhinolalia clausa is associated with all of the following except:

 A

Allergic rhinitis

 B

Palatal paralysis

 C

Adenoids

 D

Nasal polyps

Ans. B

Explanation:

Q. 6

In a patient with hypertrophied adenoids, the voice abnormality that is seen is:

 A

Rhinolalia clausa

 B

Rhinolalia aperta

 C

Hot potato voice

 D

Staccato voice

Q. 6

In a patient with hypertrophied adenoids, the voice abnormality that is seen is:

 A

Rhinolalia clausa

 B

Rhinolalia aperta

 C

Hot potato voice

 D

Staccato voice

Ans. A

Explanation:

 

  • Rhinolalia clausa is lack of nasal resonance (hyponasality).
  • It is seen in conditions which block the nose or nasopharynx as in case of allergic rhinitis, adenoids and nasal polpys.
  • Palatal paralysis will lead to hypernasality and not hyponasality.



Q. 7

Young man whose voice has not broken is called:

 A

Puberphonia

 B

Androphonia

 C

Plica ventricularis

 D

Functional aphonia

Q. 7

Young man whose voice has not broken is called:

 A

Puberphonia

 B

Androphonia

 C

Plica ventricularis

 D

Functional aphonia

Ans. A

Explanation:

  • In males at the time of puberty, the voice normally drops by an octave and becomes low pitch.
  • It occurs because vocal cords lengthen
  • Failure of this change leads to persistence of childhood high pitched voice and is called as puberphonia
  • It is seen in boys who are emotionally insecure and show excessive attachment to their mothers. Their physical and sexual development is normal

Treatment

Training the body to produce low pitched voice.

  • Gutzmann pressure test: In this test, thyroid prominence is pressed backward and downward producing low tone voice.
  • If this test is positive it indicates puberphonia.



Q. 8

Key nob appearance is seen in:

 A

Functional aphonia

 B

Puberphonia

 C

Phonasthenia

 D

Vocal cord paralysis

Q. 8

Key nob appearance is seen in:

 A

Functional aphonia

 B

Puberphonia

 C

Phonasthenia

 D

Vocal cord paralysis

Ans. C

Explanation:

Q. 9

Which of the following is not true about spasmodic dysphonia?

 A

Patient with the abductor type have strained and stran­gled voice

 B

Botulinum toxin is the standard treatment for it

 C

May be associated with other focal dysphonia

 D

Local laryngeal disorder

Q. 9

Which of the following is not true about spasmodic dysphonia?

 A

Patient with the abductor type have strained and stran­gled voice

 B

Botulinum toxin is the standard treatment for it

 C

May be associated with other focal dysphonia

 D

Local laryngeal disorder

Ans. D

Explanation:

 

Spasmodic dysphonia is not a local laryngeal disorder but a neurolgical disorder and is often associated with other dystonias, e. g. blepharospasm, oromandibular dystonias.


Q. 10

Treatment of Puberphonia is ‑

 A

Thyroplasty type I

 B

Thyroplasty type II

 C

Thyroplasty type III

 D

Thyroplasty type IV

Q. 10

Treatment of Puberphonia is ‑

 A

Thyroplasty type I

 B

Thyroplasty type II

 C

Thyroplasty type III

 D

Thyroplasty type IV

Ans. C

Explanation:

Ans. is `c’ i.e., Thyroplasty type III

Puberphonia (Mutational falset to voice)

  • In males at the time of puberty, the voice normally drops by an octave and becomes low pitch. It occurs because vocal cords lengthen.
  • Failure of this change leads to persistence of childhood high pitched voice and is called as puberphonia.
  • It is seen in boys who are emotionally insecure and show excessive attachment to their mothers. Their physical and sexual development is normal.
  • So the surgical treatment of puberphonia is lengthening of vocal cord i. e. Thyroplasty type III

THYROPLASTY

  • Isshiki divided thyroplasty procedures into 4 categories to produce functional alteration of vocal cords : –
  1. Type 1: Medial displacement of vocal cord (done by injection of gel foam/Teflon paste)
  2. Type 2 : Lateral displacement of cord (done to improve the airway).
  3. Type 3 : Lengthening (relax) the cord, to lower the pitch (gender transformation from female to male).
  4. Type 4 : Shortening (tightening) the cord, to elevate the pitch (gender transformation from male to female), for example as a treatment of androphonia.


Benign Lesions of Larynx

Benign Lesions of Larynx

Q. 1

Reinke’s space is situated in:

 A

False vocal cord

 B

True vocal cord

 C

Prelaryngeal space

 D

Retropharyngeal space

Q. 1

Reinke’s space is situated in:

 A

False vocal cord

 B

True vocal cord

 C

Prelaryngeal space

 D

Retropharyngeal space

Ans. B

Explanation:

Q. 2

A 30 year old school teacher comes to the OP complaining of hoarseness in her voice. On examination, bilateral symmetrical swelling of the membranous part of the vocal cords present.

 
Assertion: Polypoid degeneration of vocal cords is due to oedema of the subepithelial space.
 
Reason: Chronic irritation of vocal cords due to misuse of voice, heavy smoking, chronic sinusitis and laryngopharyngeal reflux are like liky to be associated in this clinical picture.
 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Q. 2

A 30 year old school teacher comes to the OP complaining of hoarseness in her voice. On examination, bilateral symmetrical swelling of the membranous part of the vocal cords present.

 
Assertion: Polypoid degeneration of vocal cords is due to oedema of the subepithelial space.
 
Reason: Chronic irritation of vocal cords due to misuse of voice, heavy smoking, chronic sinusitis and laryngopharyngeal reflux are like liky to be associated in this clinical picture.
 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Ans. A

Explanation:

In Reinke’s oedema hoarseness is the common symptom.

Patient uses false cords for voice production and this gives a low pitched and rough voice.


Q. 3

Reinke edema is associated with:

 A

Alcoholism

 B

Smoking

 C

Malnutrition

 D

None of the above

Q. 3

Reinke edema is associated with:

 A

Alcoholism

 B

Smoking

 C

Malnutrition

 D

None of the above

Ans. B

Explanation:

Reinke Edema has the following features.

  • Strong association with cigarette smoking and heavy voice use.
  • Diffuse edematous changes of the vocal cords.
  • Usually bilateral.

Q. 4

The anatomical location of Reinke’s space of larynx is in:

 A

False vocal cord

 B

True vocal cord

 C

Prelaryngeal space

 D

Retropharyngeal space

Q. 4

The anatomical location of Reinke’s space of larynx is in:

 A

False vocal cord

 B

True vocal cord

 C

Prelaryngeal space

 D

Retropharyngeal space

Ans. B

Explanation:

Under the epithelium of vocal cords is a potential space with scanty subepithelial connective tissues. It is known as Reinke’s space.

It is bounded above and below by the arcuate lines; in front, by anterior commissure, and behind by vocal process of arytenoid. Oedema of this space causes fusiform swelling of the membranous cords (Reinke’s oedema).


Q. 5

The cause for contact ulcer in vocal cords is:

 A

Voice abuse

 B

Smoking

 C

TB

 D

Malignancy

Q. 5

The cause for contact ulcer in vocal cords is:

 A

Voice abuse

 B

Smoking

 C

TB

 D

Malignancy

Ans. A

Explanation:

 

Aetiology of contact ulcers is mutli factorial but the most important cause is:

Voice abuse (faulty production of voice rather than excess use). 

 



Q. 6

Which of the following statements is not true for contact ulcer?

 A

The commonest site is the junction of anterior 1/3rd and middle 1/3rd of vocal cord and gastroesophageal reflux is the causative factor

 B

Can be caused by intubation injury

 C

The vocal process is the site and is caused/aggravated by acid reflux

 D

Can be caused by adductor dysphonia

Q. 6

Which of the following statements is not true for contact ulcer?

 A

The commonest site is the junction of anterior 1/3rd and middle 1/3rd of vocal cord and gastroesophageal reflux is the causative factor

 B

Can be caused by intubation injury

 C

The vocal process is the site and is caused/aggravated by acid reflux

 D

Can be caused by adductor dysphonia

Ans. A

Explanation:

Q. 7

A patient with hoarseness of voice was found to be having pachydermia laryngitis. All of the following are true except:

 A

It is a hyperkeratotic lesion present within the anterior 2/3rd of the vocal cords

 B

It is not premalignant lesion

 C

Diagnosis is made by biopsy

 D

On microscopy it shows acanthosis and hyperkeratosis

Q. 7

A patient with hoarseness of voice was found to be having pachydermia laryngitis. All of the following are true except:

 A

It is a hyperkeratotic lesion present within the anterior 2/3rd of the vocal cords

 B

It is not premalignant lesion

 C

Diagnosis is made by biopsy

 D

On microscopy it shows acanthosis and hyperkeratosis

Ans. A

Explanation:

 

The most common site for contact ulcers is vocal processes of the arytenoid cartilage.

Contact ulcers: / Vocal process granuloma / arytenoids granuloma / intubation granuloma.

  • Nearly exclusively seen in men over the age of 30 years.
  • Commonly located over the posterior part of vocal processes of arytenoid cartilage.
  • Can be unilateral or bilateral
  • It is multifactorial in aetiology:

Vocal abuse (most important Etiological factor) talking in a habitually low pitched cracky, hyperfunctional manner 

– Prolonged intubation

– Esophageal dysfunction (such as gastroesophageal reflux, hiatus hernia, dysmotility).

  • Symptoms

Low pitch quality of voice (most prominent feature).

– Irritation and pain in larynx which worsens on phonation or coughing and it can radiate to ear.

  • Management

–  Voice therapy along with anti reflux medications.

– In persistant cases microlaryngeal excision may be required to confirm the diagnosis and exclude malignancy.



Q. 8

Reinke’s edema is seen in:

 A

Vestibular folds

 B

Edges of vocal cords

 C

Between true and false vocal cords

 D

In pyriform fossa

Q. 8

Reinke’s edema is seen in:

 A

Vestibular folds

 B

Edges of vocal cords

 C

Between true and false vocal cords

 D

In pyriform fossa

Ans. B

Explanation:

Q. 9

Reinke’s layer seen in:

 A

Vocal cord

 B

Tympanic membrane

 C

Cochlea

 D

Reissner’s membrane

Q. 9

Reinke’s layer seen in:

 A

Vocal cord

 B

Tympanic membrane

 C

Cochlea

 D

Reissner’s membrane

Ans. A

Explanation:

Q. 10

Most common location of vocal nodule:

 A

Anterior 1/3 and posterior 2/3 junction

 B

Anterior commissure

 C

Posterior 1/3 and anterior 2/3 junction

 D

Posterior commissure

Q. 10

Most common location of vocal nodule:

 A

Anterior 1/3 and posterior 2/3 junction

 B

Anterior commissure

 C

Posterior 1/3 and anterior 2/3 junction

 D

Posterior commissure

Ans. A

Explanation:

Q. 11

True about vocal nodule is/are:

 A

Also known as screamer’s node

 B

Occur at junction of ant. 1/3rd and post. 2/3rd of vocal cords

 C

Most common presentation is aphonia

 D

a and b

Q. 11

True about vocal nodule is/are:

 A

Also known as screamer’s node

 B

Occur at junction of ant. 1/3rd and post. 2/3rd of vocal cords

 C

Most common presentation is aphonia

 D

a and b

Ans. D

Explanation:

 

  • Vocal nodules are also called singers or screamers nodes.
  • They are also the most common cause of persistent dysphonia in children
  • Most common site – at the junction of anterior 1/3 and posterior 2/3 of vocal cords.
  • Most common cause – voice abuse.
  • Most common presentation – Hoarseness of voice.
  • 0/E -They appear as bilateral white asymmetric nodules (< 3 mm) on the vocal cord

Management: First line of therapy is speech therapy

Microlaryngoscopic surgery should be reserved for cases which do not respond to voice therapy or if diagnosis is not clear.



Q. 12

Kiss ulcer of larynx is due to: 

March 2004

 A

Vocal abuse

 B

Papilloma

 C

Vocal nodule

 D

Tuberculosis

Q. 12

Kiss ulcer of larynx is due to: 

March 2004

 A

Vocal abuse

 B

Papilloma

 C

Vocal nodule

 D

Tuberculosis

Ans. A

Explanation:

Ans. A i.e. Vocal abuse



Recurrent Laryngeal Papillomatosis

Recurrent Laryngeal Papillomatosis

254325784911610

Q. 1

All of the following statements about Recurrent Laryngeal Papillomatosis are true, EXCEPT:

 A

Caused by Human Papilloma Virus (HPV)

 B

HPV6 and HPV11 are most commonly implicated

 C

HPV6 is more virulent than HPV11

 D

Transmission to neonate occurs through contact with mother during vaginal delivery

Q. 1

All of the following statements about Recurrent Laryngeal Papillomatosis are true, EXCEPT:

 A

Caused by Human Papilloma Virus (HPV)

 B

HPV6 and HPV11 are most commonly implicated

 C

HPV6 is more virulent than HPV11

 D

Transmission to neonate occurs through contact with mother during vaginal delivery

Ans. C

Explanation:

HPV 11 related Recurrent respiratory papillomatosis is more aggressive than HPV 6 mediated disease is supported by the clinical evidence.

HPV 11 does demonstrate a greater probability of producing malignant changes also.

 

Q. 2

A girl 14 yrs of age presented in emergency with mild respiratory distress. On laryngoscopy she was diagnosed to have multiple juvenile papillomatosis of the larynx. Next line of management is:

 A

Tracheostomy

 B

CO2 laser resection

 C

Steroid

 D

Antibiotics

Q. 2

A girl 14 yrs of age presented in emergency with mild respiratory distress. On laryngoscopy she was diagnosed to have multiple juvenile papillomatosis of the larynx. Next line of management is:

 A

Tracheostomy

 B

CO2 laser resection

 C

Steroid

 D

Antibiotics

Ans. B

Explanation:

Recurrent respiratory papillomatosis (RRP)  is caused by human papilloma virus (HPV), subtypes 6 and 11.

Papillomas typically appear as multiple, friable, irregular warty growths in the larynx.

These lesions particularly affect the “true” and “false” vocal cords. Patients with glottic lesions present with dysphonia; those with supraglottic lesions may present with stridor.

Treatment include CO2 laser resection, cold steel dissection, or use of the laryngeal microdebrider.

Tracheostomy should be avoided and is associated with distal airway involvement.


Q. 3

Most common manifestation of HPV infection in children –

 A

Single papilloma

 B

Multiple papillomatosis

 C

Osteoma

 D

Sarcoma

Q. 3

Most common manifestation of HPV infection in children –

 A

Single papilloma

 B

Multiple papillomatosis

 C

Osteoma

 D

Sarcoma

Ans. B

Explanation:

Ans. is ‘b’ i.e., Multiple papillomatosis

o Multiple warts are common.


Q. 4

Most common site of laryngeal papilloma in adult is

 A

Anterior commissure

 B

Posterior commissure

 C

Anterior half of vocal cord

 D

a and c

Q. 4

Most common site of laryngeal papilloma in adult is

 A

Anterior commissure

 B

Posterior commissure

 C

Anterior half of vocal cord

 D

a and c

Ans. D

Explanation:

 

Adult onset papilloma usually arise from the anterior half of the vocal cord or anterior commissure.

They are usually single, small in size, less aggressive and do not recur after surgical removal.

M/C in males (2:1), in age group 30-50 year.



Q. 5

Of the following statements about Recurrent Laryngeal papillomatosis are true, Except

 A

Caused by Human Papilloma Virus (HPV)

 B

HPV6 and HPV11 are most commonly implicated

 C

HPV6 is more virulent than HPV11

 D

Transmission to neonate occurs through contact with mother during vaginal delivery

Q. 5

Of the following statements about Recurrent Laryngeal papillomatosis are true, Except

 A

Caused by Human Papilloma Virus (HPV)

 B

HPV6 and HPV11 are most commonly implicated

 C

HPV6 is more virulent than HPV11

 D

Transmission to neonate occurs through contact with mother during vaginal delivery

Ans. C

Explanation:

 

Recurrent Laryngeal Papillomatosis / Recurrent Respiratory Papillomatosis

Etiology

  • Associated with Human Papilloma Virus infection (HPV)
  • HPV6 and HPV 11 are most commonly associated with laryngeal disease whereas HPV 16 and HPV 18 are less commonly associated.
  • HPV11 is associated with a more aggressive disease and makes the patient more prone to malignant change
  • Thus HPV 11 is more virulent

Epidemiology

  • Most commonly occur in children
  • Male female ratio – same (first born vaginally delivered child of a teenage mother is most prone)

Transmission

  • Exact mode of transmission is not known.
  • There is recognized transmission from genital warts.
  • Vertical transmission of virus from mother to child can occur either as ascending uterine infection or through direct contact in birth canal.

 

Malignant transformation in a case of papilloma occurs most commonly in distal bronchopulmonary tree and prognosis is univer­sally poor




Subglottic Stenosis

Subglottic Stenosis

Q. 1 An  8-month-old infant  had  stridor  with respiratory difficulty  which  worsened  on crying.   On   examination,  laryngoscopy showed  a red mass in the subglottic  area.  All the   following  are used  in  the treatment EXCEPT
 A CO 2 laser vaporization
 B Corticosteroids 
 C Tracheostomy 
 D Radiotherapy
Q. 1 An  8-month-old infant  had  stridor  with respiratory difficulty  which  worsened  on crying.   On   examination,  laryngoscopy showed  a red mass in the subglottic  area.  All the   following  are used  in  the treatment EXCEPT
 A CO 2 laser vaporization
 B Corticosteroids 
 C Tracheostomy 
 D Radiotherapy
Ans. D

Explanation:

[Radiotherapy]

History and examination suggest diagnosis is juvenile papilloma – They are viral in origin and multiple, often

involving infants and young children.

•      They are mostly seen on the true and false cords and the epiglottis, glistening white, irregular growth, pedunculated

•    Or sessile, friable and bleeding easily


Q. 2

The Myer-Cotton grading system is used for:

 A

Subglottic stenosis

 B

Tonsillitis

 C

Sinisitis

 D

None of the above

Q. 2

The Myer-Cotton grading system is used for:

 A

Subglottic stenosis

 B

Tonsillitis

 C

Sinisitis

 D

None of the above

Ans. A

Explanation:

The Myer-Cotton grading system describes the severity of stenosis according to the percentage of subglottic stenosis present.

The percentage is calculated by measuring the largest sized endotracheal tube that can be passed through the subglottis and comparing this with the age-appropriate tube size for the child


Q. 3

A 38 year old man presents with stridor following a respiratory infection. Cotton’s grading is used to classify the pathology. Which of the following is the diagnosis?

 A

Subglottic stenosis

 B

Laryngeal carcinoma

 C

Superior nerve palsy

 D

Vocal cord misuse

Q. 3

A 38 year old man presents with stridor following a respiratory infection. Cotton’s grading is used to classify the pathology. Which of the following is the diagnosis?

 A

Subglottic stenosis

 B

Laryngeal carcinoma

 C

Superior nerve palsy

 D

Vocal cord misuse

Ans. A

Explanation:

Subglottic stenosis (SGS) is a narrowing of the subglottic airway, which is housed in the cricoid cartilage.

Myers and Cotton devised a classification scheme for grading circumferential subglottic stenosis from I-IV.

The scale is based on a percentage of stenosis established by the age of the patient and the size of the endotracheal tube that can be placed in the airway with an air leak less than 20 cm of water pressure.

This grading system mainly applies to circumferential stenosis.

The system contains 4 grades, as follows:

  • Grade I – Obstruction of 0-50% of the lumen obstruction
  • Grade II – Obstruction of 51-70% of the lumen
  • Grade III – Obstruction of 71-99% of the lumen
  • Grade IV – Obstruction of 100% of the lumen (ie, no detectable lumen)

Q. 4

Which of the following condition of airway is classified by ‘Cotton’s grading system’?

 A

Laryngeal carcinoma

 B

Subglottic stenosis

 C

Superior laryngeal nerve palsy

 D

Vocal cord misuse

Q. 4

Which of the following condition of airway is classified by ‘Cotton’s grading system’?

 A

Laryngeal carcinoma

 B

Subglottic stenosis

 C

Superior laryngeal nerve palsy

 D

Vocal cord misuse

Ans. B

Explanation:

The Myer–Cotton grading system describes the severity of stenosis according to the percentage of subglottic stenosis present.

The percentage is calculated by measuring the largest sized endotracheal tube that can be passed through the subglottis and comparing this with the age-appropriate tube size for the child. 

A subglottic diameter of 4 mm in a full-term neonate is considered to be abnormal.

Classification

From

To

Grade I

No obstruction

50% obstruction

Grade II

51% obstruction

70% obstruction

Grade III

71% obstruction

99% obstruction

Grade IV

No detectable lumen

 

Q. 5

Subglottic stenosis in term infants is a subglottic diameter of less than:

 A

2 mm

 B

3 mm

 C

4 mm

 D

5 mm

Q. 5

Subglottic stenosis in term infants is a subglottic diameter of less than:

 A

2 mm

 B

3 mm

 C

4 mm

 D

5 mm

Ans. C

Explanation:

A subglottic diameter of less than or equal to 4 mm in a full-term neonate is considered to be abnormal.



Laryngeal involvement in miscellaneous causes

Laryngeal involvement in miscellaneous causes.

Q. 1 29-year-old male with episodic abdominal pain and stress-induced edema of the lips, the tongue, and occasionally the larynx is likely to have low functional or absolute levels of which of the following proteins?
 A C5A (Complement cascade)
 B T cell receptor, a chain
 C Cyclooxygenase
 D C1 esterase inhibitor
Q. 1 29-year-old male with episodic abdominal pain and stress-induced edema of the lips, the tongue, and occasionally the larynx is likely to have low functional or absolute levels of which of the following proteins?
 A C5A (Complement cascade)
 B T cell receptor, a chain
 C Cyclooxygenase
 D C1 esterase inhibitor
Ans. D

Explanation:

Complement activity, which results from the sequential interaction of a large number of plasma and cell-membrane proteins, plays an important role in the inflammatory response. The classic pathway of complement activation is initiated by an antibody-antigen interaction. The first complement component (C1, a complex composed of three proteins) binds to immune complexes with activation. Active C l then initiates the cleavage and concomitant activation of components C4 and C2. The activated C1 is destroyed by a plasma protease inhibitor termed C1 esterase inhibitor. This molecule also regulates clotting factor XI and kallikrein.

Patients with a deficiency of C1 esterase inhibitor may develop angioedema, sometimes leading to death by asphyxia. Attacks may be precipitated by stress or trauma. In addition to low antigenic or functional levels of C1 esterase inhibitor, patients with this autosomal dominant condition may have normal levels of Cl and C3 but low levels of C4 and C2. Danazol therapy produces a striking increase in the level of this important inhibitor and alleviates the symptoms in many patients. An acquired from of angioedema caused by a deficiency of C1 esterase inhibitor has been described in patients with autoimmune or malignant disease.


Q. 2

A man takes peanut and develop stridor, neck swelling, tongue swelling and hoarseness of voice. Most probable diagnosis is

 A >Foreign body bronchus
 B >Parapharyngeal abscess
 C

Foreign body larynx

 D

Angioneurotic edema

Q. 2

A man takes peanut and develop stridor, neck swelling, tongue swelling and hoarseness of voice. Most probable diagnosis is

 A >Foreign body bronchus
 B >Parapharyngeal abscess
 C

Foreign body larynx

 D

Angioneurotic edema

Ans. D

Explanation:

Angioneuritic edema (Ref. Harrison 17th/e p 2066 & 16riVe p 52, 1952]

  • Angioedema is essentially an anaphylaxis limited to the skin and subcutaneous tissues and can be due to drug allergy, insect stings or bites, desensitization injections or ingestion of certain foods (particularly eggs, shellfish or nuts)
  • Sometimes reactions occur explosively after ingestion of minute amounts. Others (e.g. reactions to strawberries), may occur only after overindulgence and possibly result from direct (toxic) mediator liberation.
  • It is characterized by a diffuse and painful swelling of loose subcutaneous tissue, e.g. dorsum of hands or feet, eyelids, lips, genitalia and mucous membrane. Edema of the upper airways may produce respiratory distress and the stridor may be mistaken for asthma.

Treatment

  • Epinephrine should be the first treatment for acute pharyngeal or laryngeal angioedema.
  • This may be supplemented, by a nebulized agonist (e.g. albuterol) and an I.V. antihistamine (diphenhydramine).
  • This is usually sufficient to prevent airway obstruction hut intubating or performing a tracheostomy and administering 0, might be necessary.

Also know

Urticaria

  • This is also an anaphylaxis reaction, but in urticarias the disease is limited to the superficial tissues.
  • Urticaria is characterized by local wheals and erythema in the superficial dermis whereas angioedema is a deeper swelling due to edematous areas in the deep dermis and subcutaneous tissue.
  • Generally, pruritus is the first symptom, which is followed shortly by the appearance of wheals that may remain small (1-5 mm) or enlarge. The larger ones tend to be clear in the centre and may be noticed, first as large rings

(> 20 cm across) of erythema and edema.

Also know

  • If acute angioedema is recurrent progressive, painful rather than pruritic and not associated with urticaria a

hereditary enzyme deficiency should be considerd.

  • Hereditary angioneurotic edema occurs due to loss of C1 inhibitor (regulatory protein)
  • CIF of hereditary angioneuroedema

–  Episodes of laryngeal edema

– Prominence of recurrent gastrointestinal attacks

– lack of pruritus and of urticarial lesions

  • Laboratory diagnosis of hereditary angioneuroedema

– It depends upon demonstrating the deficiency of C1 inhibitor


Q. 3

A patient presents with history of episodic painful edema of face and larynx. Which of the following is likely to be deficient in this patient?

 A

Properidin

 B

Complement C3

 C

Complement C5

 D

CI Esterase Inhibitor

Q. 3

A patient presents with history of episodic painful edema of face and larynx. Which of the following is likely to be deficient in this patient?

 A

Properidin

 B

Complement C3

 C

Complement C5

 D

CI Esterase Inhibitor

Ans. D

Explanation:

History of recurrent episodes of painful edema of face and larynx suggests a diagnosis of hereditary angioneurotic edema which is caused by deficiency of C1 esterase inhibitor.

 
C1 esterase inhibitor (C1 INH) is an  alpha-globulin, which controls the first stage of the classic complement pathway and inhibits thrombin, plasmin, and kallikrein.

Deficiency results in spontaneous activation of C1, leading to consumption of C2 and C4. It is decreased in Hereditary angioedema.
 
Ref: Pocket Guide to Diagnostic Tests, 5th Edition By Diana Nicoll, 5th Edition

Q. 4

Which of the following is false regarding scleroma of larynx?

 A

It is an acute inflammatory condition

 B

It is caused by Klebsiella

 C

Subglottic stenosis is a common complication

 D

Treatment may include steroids

Q. 4

Which of the following is false regarding scleroma of larynx?

 A

It is an acute inflammatory condition

 B

It is caused by Klebsiella

 C

Subglottic stenosis is a common complication

 D

Treatment may include steroids

Ans. A

Explanation:

It is a chronic inflammatory condition of the larynx caused by klebsiella rhinoscleromatis and treatment is with streptomycin or tetracycline often combined with steroids to prevent fibrosis.


Q. 5

An alcoholic presented with globus sensation in throat, cough and hoarseness. Larynx examination shows pseudosulcus in larynx. Pseudosulcus is seen in:

 A

Vocal abuse

 B

Tuberculosis

 C

Laryngopharyngeal reflux

 D

Chronic steroid use

Q. 5

An alcoholic presented with globus sensation in throat, cough and hoarseness. Larynx examination shows pseudosulcus in larynx. Pseudosulcus is seen in:

 A

Vocal abuse

 B

Tuberculosis

 C

Laryngopharyngeal reflux

 D

Chronic steroid use

Ans. C

Explanation:

Pseudosulcus is edema of the under surface of vocal cords giving a false impression of a sulcus vocalis; due to acid reflux into the larynx in laryngopharyngeal reflux (LPR).

Laryngeal findings in LPR:
  • Vocal cord granuloma or pseudo sulcus vocalis
  • Posterior laryngeal hypertrophy
  • Laryngeal edema and erythema
  • Cobblestoning
  • Posterior commissure bar
 

Q. 6

Most common site in respiratory tract for amyloidosis is:

 A

Lungs

 B

Larynx

 C

Nose

 D

Pharynx

Q. 6

Most common site in respiratory tract for amyloidosis is:

 A

Lungs

 B

Larynx

 C

Nose

 D

Pharynx

Ans. B

Explanation:

The larynx is the most common site in the respiratory tract for amyloid deposition.

Patient presentation is characterized by the presence of a submucosal mass, which may arise anywhere in the larynx and may impair vocal cord mobility.


Q. 7

Most common site in larynx for sarcoidosis is:

 A

Epiglottis

 B

Vocal cord

 C

Cartilage

 D

None of the above

Q. 7

Most common site in larynx for sarcoidosis is:

 A

Epiglottis

 B

Vocal cord

 C

Cartilage

 D

None of the above

Ans. A

Explanation:

One to five percent of patients with sarcoidosis present with lesions within the larynx. The epiglottis is the most common site of involvement.


Q. 8

A patient presents with history of episodic painful edema of face and larynx and abdominal pain associated with stress. Which of the following is likely to be deficient 

 A

Complement C3

 B

Complement C5

 C

CI_ Esterase Inhibitor

 D

Properidin

Q. 8

A patient presents with history of episodic painful edema of face and larynx and abdominal pain associated with stress. Which of the following is likely to be deficient 

 A

Complement C3

 B

Complement C5

 C

CI_ Esterase Inhibitor

 D

Properidin

Ans. C

Explanation:

C i.e. Cl esterase deficiency


Q. 9

Reflux laryngitis produces:

 A

Subglottic stenosis

 B

Ca larynx

 C

Cord fixation

 D

a and b

Q. 9

Reflux laryngitis produces:

 A

Subglottic stenosis

 B

Ca larynx

 C

Cord fixation

 D

a and b

Ans. D

Explanation:

 

  • There are lots of controversies regarding the reflux laryngitis secondary to reflux gastrointestinal disease. But now some studies document that there is a clear relation between the two.
  • Reflux laryngitis may have the following sequlae:

Bronchospasm

Chemical pneumonitis

Refractory subglottic stenosis

Refractory contact ulcer

Peptic laryngeal granuloma

Acid laryngitis (Heart burn, burning pharyngeal discomfort, nocturnal chocking due to interarytenoid pachydermia)

Laryngeal Carcinoma .

Laryngopharyngeal Reflux

Here classical GERD symptoms are absent. Patients have more of daytime/upright reflux without the nocturnal/supine reflux of GERD. In laryngopharyngeal reflux esophageal motility and lower esophageal sphincter is normal, while upper esophageal sphincter is abnormal. The traditional diagnostic tests for GERD are not useful in LPR.

Symptom Chronic or Intermittent dysphonia, vocal strain, foreign body sensation, excessive throat mucus, Postnasal discharge and cough. Laryngeal findings: Interarytenoid bunching, Posterior laryngitis and subglottic edema (Pseudosulcus)

Sequelae of Laryngopharyngeal Reflux

  • Subglottic stenosis
  • Carcinoma larynx
  • Contact ulcer/granuloma
  • Cricoarytenoid joint fixity
  • Vocal nodule/polyp
  • Sudden infant deaths
  • Laryngomalacia (Association)

Treatment is in similar lines as GERD, but we need to give proton pump inhibitors at a higher dose and for a longer duration (at least 6-8 months).



Q. 10

Patient following peanut consumption presented with laryngeal edema, stridor, hoarseness of voice and swell­ing of tongue. Most likely diagnosis is

 A

Angioneurotic edema

 B

Pharyngeal abscess

 C

Foreign body larynx

 D

Foreign body bronchus

Q. 10

Patient following peanut consumption presented with laryngeal edema, stridor, hoarseness of voice and swell­ing of tongue. Most likely diagnosis is

 A

Angioneurotic edema

 B

Pharyngeal abscess

 C

Foreign body larynx

 D

Foreign body bronchus

Ans. A

Explanation:

 

Allergic angloedema: Most common type and usually affects those with some kind of food allergy.

It can also be caused by insect bites, contact with latex, and some medications, such as penicillin or aspirin.

In severe cases the throat can swell, making it hard for the patient to breath.



Q. 11

A patient with burns die within 24 hours. What could be the most probable cause:

 A

Circulatory shock

 B

Physical burn injury to the airways above the larynx

 C

Physical burn injury to the airways below the larynx

 D

Circumferential burn

Q. 11

A patient with burns die within 24 hours. What could be the most probable cause:

 A

Circulatory shock

 B

Physical burn injury to the airways above the larynx

 C

Physical burn injury to the airways below the larynx

 D

Circumferential burn

Ans. B

Explanation:

Ans. B: Physical burn injury to the airways above the larynx

Inflammatory and circulatory changes in burn patient produce a net flow of water, solutes and proteins from the intravascular to extravascular space.

This flow occurs over the first 36 hours after the injury.

As the burn size approaches 10-15% of the total body surface area (TBSA), the loss of intravascular fluid can cause a level of circulatory shock Once burned, the linings of nose, mouth, tongue, palate and larynx will start to swell.

After a few hours, they may start interfere with the larynx and may completely block the airway, if action is not taken to secure an airway Physical burn injury to the airways below the larynx is a rare injury

Circumferential burns may compromise circulation to a limb



Neonatal Airway

Neonatal Airway

Q. 1

Why is a child abler to breathe and suckle at the same time 

 A

Short soft palate

 B

Short tongue

 C

High placed larynx

 D

Small pharynx

Q. 1

Why is a child abler to breathe and suckle at the same time 

 A

Short soft palate

 B

Short tongue

 C

High placed larynx

 D

Small pharynx

Ans. C

Explanation:

High placed larynx 

  • A baby can suck milk into mouth and because of its palate its mouth is separated from its nasal cavity so white it is sucking in milk it can also breathe through its nose.
  • When the infant has to swallow the soft palate rapidly moves upward to close off the hack of the nasal air tube.
  • At the same time, the epiglottis closes off the larynx and guides the milk into the esophagus (food tube).
  • Because of these factors infants can breath and swallow in quick succession.

–  Its lumen is short and. funnel shaped and disproportionately narrower than that of adult.

It lies higher in the neck than the adult larynx.

-It rest the upper border of the infant epiglottis is at the level of the second or third cervical vertebrae.

–   When larynx is elevated it reaches the level of first cervical vertebrae.

– This high position enables an infant to use its nasal airway to breathe while sucking.


Q. 2

TRUE about infant airway compared to adult airway are all, EXCEPT:

 A

The relatively large size of the tongue

 B

Epiglottis is omega shaped

 C

Larynx is funnel shaped

 D

None of the above

Q. 2

TRUE about infant airway compared to adult airway are all, EXCEPT:

 A

The relatively large size of the tongue

 B

Epiglottis is omega shaped

 C

Larynx is funnel shaped

 D

None of the above

Ans. D

Explanation:

Differences in airway anatomy make the potential for technical airway difficulties greater in infants than in teenagers or adults. The airway of infants differs in five ways:

(1) the relatively large size of the infant’s tongue in relation to the oropharynx increases the likelihood of airway obstruction and technical difficulties during laryngoscopy;

(2) the larynx is located higher (more cephalic) in the neck, thus making straight blades more useful than curved blades;

(3) the epiglottis is shaped differently, being short, stubby, omega shaped, and angled over the laryngeal inlet; control with the laryngoscope blade is therefore more difficult;

(4) the vocal cords are angled, so a “blindly” passed endotracheal tube may easily lodge in the anterior commissure rather than slide into the trachea; and

(5) the infant larynx is funnel shaped.

Ref: Miller’s anesthesia-7th ed, Chapter 82.

Q. 3

The narrowest part of trachea in a newborn is at the level of:

 A

Cricoid

 B

Thyroid

 C

Vocal cords

 D

Subglottic

Q. 3

The narrowest part of trachea in a newborn is at the level of:

 A

Cricoid

 B

Thyroid

 C

Vocal cords

 D

Subglottic

Ans. A

Explanation:

Neonates and infants have, compared with older children and adults, a proportionately larger head and tongue, narrower nasal passages, an anterior and cephalad larynx (the glottis is at a vertebral level of C4 versus C6 in adults),
a longer epiglottis, and a shorter trachea and neck.
These anatomic features make neonates and young infants obligate nasal breathers until about 5 months of age.
The cricoid cartilage is the narrowest point of the airway in children younger than 5 years of age; in adults, the narrowest point is the glottis. One millimeter of mucosal edema will have a proportionately greater effect on gas flow in children because of their smaller tracheal diameters.
 
Ref: Butterworth IV J.F., Butterworth IV J.F., Mackey D.C., Wasnick J.D., Mackey D.C., Wasnick J.D. (2013). Chapter 42. Pediatric Anesthesia. In J.F. Butterworth IV, J.F. Butterworth IV, D.C. Mackey, J.D. Wasnick, D.C. Mackey, J.D. Wasnick (Eds), Morgan & Mikhail’s Clinical Anesthesiology, 5e.

Q. 4

Which of the following feature of airways can make babies enable breathing while suckling breast milk?

 A

Short, wide tongue

 B

Small pharynx

 C

Higher position of larynx

 D

Small soft palate

Q. 4

Which of the following feature of airways can make babies enable breathing while suckling breast milk?

 A

Short, wide tongue

 B

Small pharynx

 C

Higher position of larynx

 D

Small soft palate

Ans. C

Explanation:

Paediatric larynx:

  • Infant’s larynx is positioned high in the neck opposite C3 or C4 (vocal cord level ) at rest and reaches C1 or C2 during swallowing.

  • This high position allows the epiglottis to meet soft palate and make a nasopharyngeal channel for nasal breathing during suckling.

  • The milk feed passes separately over the dorsum of tongue and the side of epiglottis, thus allowing breathing and feeding to go on simultaneously.

Ref: Diseases of Ear, Nose and Throat by PL Dhingra, 4th edition, Page 262.


Q. 5

New born babies are able to breathe and suck at the same time due to –

 A

Wide short tongue

 B

Short soft palate

 C

High larynx

 D

Short

Q. 5

New born babies are able to breathe and suck at the same time due to –

 A

Wide short tongue

 B

Short soft palate

 C

High larynx

 D

Short

Ans. C

Explanation:

Ans. is ‘c’ i.e., High larynx

o The infant larynx differs markedly from its adult counterpart. Although it is about one – third adult size, it is proportionately larger. Its lumen is short and funnel – shaped and disproportionately narrower than that of adult. It lies higher in the neck than the adult larynx. At rest, the upper border of the infant epiglottis is at the level of the second or third cervical vertebra; when the larynx is elevated, it reaches the level of the first cervical vertebra. This high position enables an infant to use its nasal airway to breath while sucking.


Q. 6

True about upper airways of neonate-

 A

Cricoid is narrowest part

 B

Larynx extend from C4 to C6

 C

Epiglottis is big & omega shaped

 D

All

Q. 6

True about upper airways of neonate-

 A

Cricoid is narrowest part

 B

Larynx extend from C4 to C6

 C

Epiglottis is big & omega shaped

 D

All

Ans. C

Explanation:

Ans. is ‘c’ i.e., Epiglottis is big & omega shaped

Anatomy of airway in neonate

The anatomy of the upper airway predisposes to obstruction. Its characteristic features are

o Proportionately larger head and tongue, the tongue is often pushed against the palate

o Narrow nasal passages

o Anterior and cephalad larynx (the larynx is anteriorly inclined)

o Epiglottis is soft, large and patulous, Omega shaped and inclined at 45°.

  • The Subglottic region rather than the rima glottidis is the narrowest portion of the airway.
  • Vocal cord is at the level of C,
  • Trachea bifurcates at the level of T2

o Larynx lies opposite Pd, 3′d and 4th cervical vertebra at birth.


Q. 7

The narrowest part of larynx in infants is at the cricoid level. In administering anesthesia this may lead to all except.

 A

Choosing a smaller size endotracheal tube

 B

Trauma to the subglottic region

 C

Post operative stridor

 D

Laryngeal oedema

Q. 7

The narrowest part of larynx in infants is at the cricoid level. In administering anesthesia this may lead to all except.

 A

Choosing a smaller size endotracheal tube

 B

Trauma to the subglottic region

 C

Post operative stridor

 D

Laryngeal oedema

Ans. A

Explanation:

A i.e. Choosing a smaller size endotracheal tube

  • Endotracheal tube that passes through the glottis may still impinge upon the cricoid cartilage; the cricoid cartilage is the narrowest point of the airway in children younger than 5 years of ageQ
  • Mucosal trama can cause post operative edema, stridor, croup & airway obstruction() in subglottic & glotic region
  • The appropiate size of tube is estimated by an age based formula, which provides only a rough guide line however. Exceptions include premature neonates (2.5 to 3 mm tube) and full term neonates (3-3.5 mm tube)
  • Correct tube size is confirmed by easy passage into the larynx and the development of gas leak at 15-20 cm H20 pressure. So the size of ETT depends on age, easy passage & gasleak at 15-20 cm H20 pressure.

Q. 8

Narrowest part of infantile larynx is:

 A

Supraglottic

 B

Subglottic

 C

Glottic

 D

None of the above

Q. 8

Narrowest part of infantile larynx is:

 A

Supraglottic

 B

Subglottic

 C

Glottic

 D

None of the above

Ans. B

Explanation:

 

The diameter of cricoid cartilage is smaller than the size of glottis, making subglottis the narrowest part


Q. 9

A neonate while suckling milk can respire without dif­ficulty due to:

 A

Start soft palate

 B

Small tongue

 C

High larynx

 D

Small pharynx

Q. 9

A neonate while suckling milk can respire without dif­ficulty due to:

 A

Start soft palate

 B

Small tongue

 C

High larynx

 D

Small pharynx

Ans. C

Explanation:

 

Infant’s larynx is positioned high in the neck level of glottis being opposite to C3 or C4 at rest and reaches Cl or C2 during swal­lowing. This high position allows the epiglottis to meet soft palate and make anasopharyngeal channel for nasal breathing during suckling.The milk feed passes separately over the dorsum of tongue and the side of epiglottis, thus allowing breathing and feeding to go on simultaneously.


Q. 10

All are true statement about tracheostomy and larynx in children except:

 A

Omega shaped epiglottis

 B

Laryngeal cartilages are soft and collapsable

 C

Larynx is high in children

 D

Trachea can be easily palpated

Q. 10

All are true statement about tracheostomy and larynx in children except:

 A

Omega shaped epiglottis

 B

Laryngeal cartilages are soft and collapsable

 C

Larynx is high in children

 D

Trachea can be easily palpated

Ans. D

Explanation:

 

Infant’s larynx differs from adult in:

  • It is situated high up (C2 – C4).Q (in adults = C3 – C6)
  • Of equal size in both sixes (in adults it is larger in males)
  • Larynx is funnel shaped
  • The narrowest part of the infantile larynx is the junction of subglottic larynx with trachea and this is because cricoid cartilage is very small
  • Epiglottis is omega shaped, soft, large and patulous.
  • Laryngeal cartilages are soft and collapse easily
  • Short trachea and short neck.
  • Vocal cords are angled and lie at level of C4
  • Trachea bifurcates at level of T2
  • Thyroid cartilage is flat. The cricothyroid and thyrohyoid spaces are narrow.

Tracheostomy in Infants and Children                                                                                                              

Trachea of infants and children is soft and compressible and its identification may become difficult and the surgeon may easily displace it and go deep or lateral to it injuring recurrent laryngeal nerve or even the carotid.

During positioning, do not extend too much as this pulls structures from chest into the neck and thus injury may occur to pleura, innominate vessels and thymus or the tracheostomy opening may be made twoo low near suprasternal notch

Tracheostomy in Infants and Children                                                                                               

The incision is a short transverse one, midway between lower border of thyroid cartilage and the suprasternal notch. The neck must be well extended.

A incision is made through two tracheal rings, preferably the third or fourth.




Tubercular Laryngitis

Tubercular Laryngitis

Q. 1

Which of the following is seen in TB of larynx?

 A

Mammilated appearance

 B

Mouse nibbled appearance

 C

Turban epiglottis

 D

All of the above

Q. 1

Which of the following is seen in TB of larynx?

 A

Mammilated appearance

 B

Mouse nibbled appearance

 C

Turban epiglottis

 D

All of the above

Ans. D

Explanation:

Q. 2

Which of the following is not true about TB larynx?

 A

Turban epiglottis

 B

Odynophagia

 C

Paralysis of vocal cord

 D

Ulceration of arytenoids

Q. 2

Which of the following is not true about TB larynx?

 A

Turban epiglottis

 B

Odynophagia

 C

Paralysis of vocal cord

 D

Ulceration of arytenoids

Ans. C

Explanation:

Weakness of voice is the earliest symptom followed by hoarseness.

Swallowing is painful with marked dysphagia in later stages.

Laryngeal examination shows pseudoedema of the epiglottis – ‘Turban epiglottis’. Superficial ragged ulceration on the arytenoids and interarytenoid region.


Q. 3

Tubercular laryngitis affects primarily:

 A

Anterior commissure

 B

Posterior commissure of larynx

 C

Anywhere within the larynx

 D

Superior surface of larynx

Q. 3

Tubercular laryngitis affects primarily:

 A

Anterior commissure

 B

Posterior commissure of larynx

 C

Anywhere within the larynx

 D

Superior surface of larynx

Ans. B

Explanation:

 

Tuberculosis affects posterior part of larynx more than anterior part.

Parts affected are: Inter arytenoid fold > Ventricular bands > Vocal cords > Epiglottis



Q. 4

True about TB larynx:

 A

‘Turban’ epiglottis

 B

Odynophagia

 C

Cricoarytenoid fixation 

 D

a and b

Q. 4

True about TB larynx:

 A

‘Turban’ epiglottis

 B

Odynophagia

 C

Cricoarytenoid fixation 

 D

a and b

Ans. D

Explanation:

Q. 5

Infection involving anterior larynx:

 A

TB

 B

Sarcoidosis

 C

Syphilis

 D

All the above

Q. 5

Infection involving anterior larynx:

 A

TB

 B

Sarcoidosis

 C

Syphilis

 D

All the above

Ans. D

Explanation:

Q. 6

Turban epiglottitis is a clinical finding in ‑

 A

Tubercular laryngitis

 B

Tubercular pharyngitis

 C

Polypoid degeneration of vocal cord

 D

Subglottic hemangioma

Q. 6

Turban epiglottitis is a clinical finding in ‑

 A

Tubercular laryngitis

 B

Tubercular pharyngitis

 C

Polypoid degeneration of vocal cord

 D

Subglottic hemangioma

Ans. A

Explanation:

Ans. is ‘a’ i.e., Tubercular laryngitis

Laryngeal examination in TB laryngitis

  • Hyperaemia of the vocal cord in its whole extent or confined to posterior part with impairment of adduction is the first sign.
  • Swelling in the interarytenoid region giving a mammilated appearance.
  • Ulceration of vocal cord giving mouse-nibbled appearance.
  • Superficial ragged ulceration on the arytenoids and interarytenoid region.
  • Granulation tissue in interarytenoid region or vocal process of arytenoid.
  • Pseudoedema of the epiglottis “turban epiglottis”.
  • Swelling of ventricular bands and aryepiglottic folds.
  • Marked pallor of surrounding mucosa.


Laryngeal Nerve Supply

Laryngeal Nerve Supply

Q. 1

Which of the following laryngeal muscle is supplied by external laryngeal nerve?

 A

Cricothyroid

 B

Thyroarytenoid

 C

Cricoarytenoid

 D

Vocalis

Q. 1

Which of the following laryngeal muscle is supplied by external laryngeal nerve?

 A

Cricothyroid

 B

Thyroarytenoid

 C

Cricoarytenoid

 D

Vocalis

Ans. A

Explanation:

External laryngeal nerve is a branch of superior laryngeal nerve and supplies cricothyroid muscle.

Superior laryngeal nerve arise from inferior ganglion of the vagus descends behind the internal carotid artery and at the level of greater cornua of hyoid bone, divides into external and internal branches.

The internal branch pierces the thyrohyoid membrane and supplies sensory innervation to the larynx and hypopharynx.


Q. 2

All the muscles of the larynx are supplied by the recurrent laryngeal nerve, EXCEPT?

 A

Cricothyroid

 B

Salpingopharyngeus

 C

Stylopharyngeus

 D

None of the above

Q. 2

All the muscles of the larynx are supplied by the recurrent laryngeal nerve, EXCEPT?

 A

Cricothyroid

 B

Salpingopharyngeus

 C

Stylopharyngeus

 D

None of the above

Ans. A

Explanation:

All the intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerve except for cricothyroid, which is supplied by the external laryngeal nerve.

 


Q. 3

Nerve supply of the mucosa of larynx is ‑

 A

External laryngel and recurent laryngeal

 B

Internal laryngeal

 C

External laryngeal

 D

Superior laryngeal

Q. 3

Nerve supply of the mucosa of larynx is ‑

 A

External laryngel and recurent laryngeal

 B

Internal laryngeal

 C

External laryngeal

 D

Superior laryngeal

Ans. B

Explanation:

 Internal laryngeal


Q. 4

Recurrent laryngeal nerve is in close association with‑

 A

Superior thyroid artery

 B

Inferior thyroid artery

 C

Middle thyroid vein

 D

Superior thyroid vein

Q. 4

Recurrent laryngeal nerve is in close association with‑

 A

Superior thyroid artery

 B

Inferior thyroid artery

 C

Middle thyroid vein

 D

Superior thyroid vein

Ans. B

Explanation:

Ans. is (b) i.e. Inferior thyroid artery 

Inferior thyroid artery is a branch of the thyrocervical trunk. During its course it passes behind the carotid sheath and the middle cervical sympathetic ganglion and its terminal part is related to the recurrent laryngeal nerve.

More Questions about arterial supply of the thyroid gland

  • The thyroid gland in supplied by the following arteries

i)           Superior thyroid artery

a branch of the external carotid artery

lies in close association with the external laryngeal nerve.

ii)         Inferior thyroid artery

a branch of the thyrocervical trunk (which arises from the subclavian artery) its terminal part is intimately related to the recurrent laryngeal nerve. Major supply of the parathyroid glands

iii)        Acessory thyroid arteries

– arise from tracheal and esophageal arteries

v) Thyroidea ima artery (or the lowest thyroid artery)

– found in only about 3% of individuals

– arises from the brachicephalic trunk or directly from the arch of aorta.

  • During thyroidectomy the superior thyroid artery is ligated near to gland (to save the external laryngeal nerve); and the inferior thyroid artery is ligated away from the gland (to save the recurrent laryngeal nerve)

Questions on venous drainage of thyroid gland

  • The thyroid gland is drained by the following veins

i) Superior thyroid vein.

–  Drains in the internal jugular vein or

–  the common facial vein

ii)         Middle thyroid vein

Also drains in the internal jugular vein

iii)        Inferior thyroid vein

–  Drains into the left brachiocephalis vein

iv) A fourth thyroid vein (of Kocher),

– may emerge between middle and inferior veins and

–  drains into the internal jugular vein


Q. 5

Sensory nerve supply of larynx below the level of vocal cord is:

 A

External branch of superior laryngeal nerve

 B

Internal branch of superior laryngeal nerve

 C

Recurrent laryngeal nerve

 D

Inferior pharyngeal

Q. 5

Sensory nerve supply of larynx below the level of vocal cord is:

 A

External branch of superior laryngeal nerve

 B

Internal branch of superior laryngeal nerve

 C

Recurrent laryngeal nerve

 D

Inferior pharyngeal

Ans. C

Explanation:

 

Nerve supply of larynx

  • Sensory:

The internal laryngeal nerve supplies the mucous membrane up to the level of the vocal folds.

–  The recurrent laryngeal nerve supplies below the level of the vocal folds.

  • Motor:

–  All intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerve except for the cricothyroid which is supplied by the external laryngeal nerve.



Q. 6

Most common nerve injured in ligation of superior thyroid artery:

 A

Recurrent laryngeal nerve

 B

Facial nerve

 C

Mandibular nerve

 D

External laryngeal nerve

Q. 6

Most common nerve injured in ligation of superior thyroid artery:

 A

Recurrent laryngeal nerve

 B

Facial nerve

 C

Mandibular nerve

 D

External laryngeal nerve

Ans. D

Explanation:

 

  • The external laryngeal nerve lies in relation to superior thyroid artery.
  • The recurrent laryngeal nerve lies close to inferior thyroid artery.



Q. 7

Recurrent laryngeal nerve supplies all of the following muscles except:           

September 2005

 A

Cricothyroid

 B

Lateral cricoarytenoid

 C

Posterior cricoarytenoid

 D

Thyroepiglotticus

Q. 7

Recurrent laryngeal nerve supplies all of the following muscles except:           

September 2005

 A

Cricothyroid

 B

Lateral cricoarytenoid

 C

Posterior cricoarytenoid

 D

Thyroepiglotticus

Ans. A

Explanation:

Cricothyroid


Q. 8

The muscle which is not supplied by recurrent laryngeal nerve is

 A

Thyroarytenoid

 B

Posterior cricoarytenoid

 C

Cricothyroid

 D

Lateral cricoarytenoid

Q. 8

The muscle which is not supplied by recurrent laryngeal nerve is

 A

Thyroarytenoid

 B

Posterior cricoarytenoid

 C

Cricothyroid

 D

Lateral cricoarytenoid

Ans. C

Explanation:

Adductor of vocal cords

  • Thyroarytenoid muscle:

–   R and L muscles; attached to thyroid and arytenoid cartilages on each side.

Action shortens and relaxes vocal ligament.

Note: deeper inner fibers referred to as “vocalis muscle”.

  • Lateral cricoarytenoid muscle: (R and L muscles):

–  Attached to cricoid and arytenoid cartilage on each side.

– Closes or adducts vocal folds.

–  Supplied by Recurrent laryngeal nerve.

  • Cricothyroid muscle:

Attached to cricoid and thyroid cartilages.

Tilts the thyroid cartilage, thus increasing tension of vocal folds

Supplied by external laryngeal nerve

  • Inter-arytenoid muscle (transverse and oblique)

– Attached between right and left arytenoid cartilages

– Closes inlet of larynx

– Supplied by Recurrent laryngeal nerve Abductor of vocal cords

  • Posterior cricoarytenoid muscle

Attached to cricoid and arytenoid cartilages

Move arytenoid cartilages so as to move both vocal folds apart, “open” of abduct vocal folds

Supplied by Recurrent laryngeal nerve

Vocalis muscle (derived from inner and deeper fibers of thyroarytenoid msucle)

Supplied by Recurrent laryngeal nerve

All intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerve except for cricothyroid which is supplied by external laryngeal nerve.


Q. 9

Galen’s anastomosis is between ‑

 A

Recurrent laryngeal nerve and external laryngeal nerve

 B

Recurrent laryngeal nerve and internal laryngeal nerve

 C

Internal laryngeal nerve and external laryngeal nerve

 D

None of the above

Q. 9

Galen’s anastomosis is between ‑

 A

Recurrent laryngeal nerve and external laryngeal nerve

 B

Recurrent laryngeal nerve and internal laryngeal nerve

 C

Internal laryngeal nerve and external laryngeal nerve

 D

None of the above

Ans. B

Explanation:

There are two types of important anastmosis between laryngeal branches of vagus :‑

1) Galen anastomosis (Ramus anastomoticus or Ansa of Galen)

 This is an anastomosis between the recurrent laryngeal nerve and internal laryngeal nerve (internal branch of superior laryngeal nerve).

 Generally, posterior branch of recurrent laryngeal nerve contributes to the anastomosis; however, anterior branch can also contribute.

2) Human communicating nerve

It is an anastomosis between recurrent laryngeal nerve (distal part) and external laryngeal nerve (external branch of superior laryngeal nerve).


Q. 10

Nerve supply of cricothyroid‑

 A

Recurrent laryngeal nerve

 B

Internal laryngeal nerve

 C

External laryngeal nerve

 D

Mandibular nerve

Q. 10

Nerve supply of cricothyroid‑

 A

Recurrent laryngeal nerve

 B

Internal laryngeal nerve

 C

External laryngeal nerve

 D

Mandibular nerve

Ans. C

Explanation:

 External laryngeal nerve



Laryngeal Paralysis

Laryngeal Paralysis

Q. 1

Cadaveric position of vocal cords is seen in

 A

Bilateral recurrent and superior laryngeal nerve palsy

 B

Bilateral recurrent laryngeal nerve palsy

 C

Unilateral superior laryngeal nerve palsy

 D

Bilateral superior laryngeal nerve palsy

Q. 1

Cadaveric position of vocal cords is seen in

 A

Bilateral recurrent and superior laryngeal nerve palsy

 B

Bilateral recurrent laryngeal nerve palsy

 C

Unilateral superior laryngeal nerve palsy

 D

Bilateral superior laryngeal nerve palsy

Ans. A

Explanation:

 

Position of cord

Location from midline

Defect

Median

midline

RLN palsy

Paramedian

1.5 mm

RLN palsy

Intermediate

3.5 mm

Both RLN and superior laryngeal nerve palsy

Gentle abduction

7.5mm

ADDUCTOR PALSY


Q. 2

Bilateral recurrent laryngeal nerve palsy is seen in:

 A

Thyroidectomy

 B

Carcinoma thyroid

 C

Cancer cervical oesophagus

 D

All of the above

Q. 2

Bilateral recurrent laryngeal nerve palsy is seen in:

 A

Thyroidectomy

 B

Carcinoma thyroid

 C

Cancer cervical oesophagus

 D

All of the above

Ans. D

Explanation:

Q. 3

Complications of Hemithyroidectomy include all of the following, except?

 A

Hypocalcemia

 B

Wound hematoma

 C

Recurrent laryngeal nerve palsy

 D

External branch of superior laryngeal nerve palsy

Q. 3

Complications of Hemithyroidectomy include all of the following, except?

 A

Hypocalcemia

 B

Wound hematoma

 C

Recurrent laryngeal nerve palsy

 D

External branch of superior laryngeal nerve palsy

Ans. A

Explanation:

Hypocalcemia following total or subtotal thyroidectomy where all four parathyroid glands are either removed results due to parathyroid insufficiency.

Parathyroid insufficiency (hypocalcemia) is usually not seen after Hemithyroidectomy as it involves the removal of only one lobe of thyroid together with the isthmus and the parathyroids are preserved.

 
Ref: Bailey and Love’s Short Practice of Surgery, 25th Edition, Page 782

Q. 4

In complete bilateral palsy of recurrent laryngeal nerves, there is:

 A

Complete loss of speech with stridor and dyspnea

 B

Complete loss of speech but no difficulty in breathing

 C

Preservation of speech with severe stridor and dyspnea

 D

Preservation of speech and no difficulty in breathing

Q. 4

In complete bilateral palsy of recurrent laryngeal nerves, there is:

 A

Complete loss of speech with stridor and dyspnea

 B

Complete loss of speech but no difficulty in breathing

 C

Preservation of speech with severe stridor and dyspnea

 D

Preservation of speech and no difficulty in breathing

Ans. C

Explanation:

In patients having bilateral paralysis of recurrent laryngeal nerve, the airway is inadequate since both the cords lie in the median and paramedian position causing dyspnoea and stridor but the voice is preserved.


Q. 5

Cadaveric position of vocal cords is seen in:

 A

Bilateral recurrent and superior laryngeal nerve palsy

 B

Bilateral recurrent laryngeal nerve palsy

 C

Unilateral superior laryngeal nerve palsy

 D

Bilateral superior laryngeal nerve palsy

Q. 5

Cadaveric position of vocal cords is seen in:

 A

Bilateral recurrent and superior laryngeal nerve palsy

 B

Bilateral recurrent laryngeal nerve palsy

 C

Unilateral superior laryngeal nerve palsy

 D

Bilateral superior laryngeal nerve palsy

Ans. A

Explanation:

In bilateral recurrent and superior laryngeal nerve palsy all the laryngeal muscles are paralysed and both cords lie in the cadaveric position i.e 3.5mm from the midline. There is also total anaesthesia of the larynx.

  • In bilateral recurrent laryngeal nerve palsy, vocal cords lie in median or paramedian position due to unapposed action of cricothyroid muscles. 
  • In unilateral paralysis of superior laryngeal nerve, there is shortening of the cord with loss of tension. The paralysed cord appears wavy due to lack of tension.

Q. 6

Twenty-four hours following partial thyroidectomy where the inferior thyroid artery was also ligated (tied off), the patient now spoke with a hoarse voice (whisper), and had difficulty in breathing. Which nerve was injured?

 A

Internal branch of superior laryngeal

 B

Ansa cervicalis

 C

Ansa subclavia

 D

Recurrent laryngeal

Q. 6

Twenty-four hours following partial thyroidectomy where the inferior thyroid artery was also ligated (tied off), the patient now spoke with a hoarse voice (whisper), and had difficulty in breathing. Which nerve was injured?

 A

Internal branch of superior laryngeal

 B

Ansa cervicalis

 C

Ansa subclavia

 D

Recurrent laryngeal

Ans. D

Explanation:

The recurrent laryngeal nerve runs with the inferior thyroid artery toward the lower lobes of the thyroid,
This means that the recurrent laryngeal nerve would be at risk in any surgery involving the inferior thyroid artery or the inferior poles of the thyroid.
The recurrent laryngeal nerve becomes the inferior laryngeal nerve at the inferior border of cricopharyngeus, and this nerve continues on to innervate all the muscles of the larynx with the exception of cricothyroid. So, an injury to the recurrent laryngeal nerve might lead to hoarseness and difficulty breathing (due to a laryngeal spasm).
 

 
.

Q. 7

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

 A

Recurrent laryngeal

 B

External laryngeal

 C

Internal laryngeal

 D

Superior laryngeal

Q. 7

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

 A

Recurrent laryngeal

 B

External laryngeal

 C

Internal laryngeal

 D

Superior laryngeal

Ans. A

Explanation:

Recurrent laryngeal nerve injury is the most common cause of vocal cord paralysis. It from the Vagus, travels further on the left where it loops around the arch of Aorta while on the right, it travels around the subclavian artery. Supplies all the muscles (posterior Cricoarytenoid, interarytenoid, lateral Cricoarytenoid, and Thyroarytenoid muscles) except for Cricothyroid.

Laryngeal Nerve Paralysis: Three areas where damage can occur
  • Brainstem Nuclei
  • Corticobulbar fibers start from the cerebral cortex and descend through the internal capsule and synapse at the nucleus ambiguus in the Medulla
  • Vagus Nerve
  • Recurrent Laryngeal Nerve is the commonest cause.
Recurrent laryngeal nerve:
Arises from the Vagus, travels further on the left where it loops around the arch of Aorta while on the right, it travels around the subclavian artery. The intrinsic muscles of the larynx, all of which are innervated by the recurrent laryngeal nerve, include the:
1. Posterior cricoarytenoid the ONLY abductor of the vocal folds. Functions to open the glottis by rotary motion on the arytenoid cartilages. Also tenses cords during phonation.
2. Lateral cricoarytenoid functions to close glottis by rotating arytenoids medially.
3. Transverse arytenoid only unpaired muscle of the larynx. Functions to approximate bodies of arytenoids closing posterior aspect of glottis.
4. Oblique arytenoid this muscle plus action of transverse arytenoid function to close laryngeal introitus during swallowing.
5. Thyroarytenoid – very broad muscle, usually divided into three parts:
  • Thyroarytenoideus internus (vocalis) – adductor and major tensor of free edge of vocal fold.
  • Thyroarytenoideus externus – major adductor of vocal fold
  • Thyroepiglotticus – shortens vocal ligaments
The cricothyroid muscle is considered to be an extrinsic muscle of the larynx because it is innervated by the external branch of the superior laryngeal nerve. It functions to increase tension in the vocal folds, especially at the upper range of pitch or loudness.

Q. 8

Damage to the internal laryngeal nerve results in

 A

Hoarseness

 B

Loss of timbre of voice

 C

Anaesthesia of the larynx

 D

Brathing difficulty

Q. 8

Damage to the internal laryngeal nerve results in

 A

Hoarseness

 B

Loss of timbre of voice

 C

Anaesthesia of the larynx

 D

Brathing difficulty

Ans. C

Explanation:

 Anesthesia of larynx


Q. 9

Thyroid Ca causes laryngeal paralysis due to

 A

Recurrent laryngeal nerve palsy

 B

Vagus nerve palsy

 C

Glossopharyngeal nerve palsy

 D

Hypoglossal nerve palsy

Q. 9

Thyroid Ca causes laryngeal paralysis due to

 A

Recurrent laryngeal nerve palsy

 B

Vagus nerve palsy

 C

Glossopharyngeal nerve palsy

 D

Hypoglossal nerve palsy

Ans. A

Explanation:

Ans. is ‘a’ i.e. Recurrent laryngeal nerve palsy

The nerves found in close relationship to thyroid gland and therefore likely to be involved in malignant spread and thyroid surgery are – recurrent laryngeal nerve and – superior laryngeal nerve.


Q. 10

Complications of Hemithyroidectomy include all of the following Except?

 A

Hypocalcemia

 B

Wound hematoma

 C

Recurrent laryngeal nerve palsy

 D

External branch of superior laryngeal nerve palsy

Q. 10

Complications of Hemithyroidectomy include all of the following Except?

 A

Hypocalcemia

 B

Wound hematoma

 C

Recurrent laryngeal nerve palsy

 D

External branch of superior laryngeal nerve palsy

Ans. A

Explanation:

Ans. is ‘a’ i.e. Hypocalcemia 

“Transient or permanent hypocalcemia is very unlikely after hemithyroidectomy, since the opposite lobe is not

disturbed.”- Endocrine surgery by Arthur E. Schwartz

Hypocalcemia is seen after total or subtotal thyroidectomy d/t inadvertent removal of parathyroid glands or their injury during surgery.


Q. 11

After thyroidectomy, pt. developed stridor within 2 hrs. All are likely cause of stridor except :

 A

Hypocalcemia

 B

Recurrent laryngeal nerve palsy

 C

Laryngomalacia

 D

Wound hematoma

Q. 11

After thyroidectomy, pt. developed stridor within 2 hrs. All are likely cause of stridor except :

 A

Hypocalcemia

 B

Recurrent laryngeal nerve palsy

 C

Laryngomalacia

 D

Wound hematoma

Ans. A

Explanation:

Ans. is ‘a’ i.e. hypocalcemia 

  • Though hypocalcemia can cause stridor d/t laryngeal spasm, it is seen 2-5 days after operation. Bailey and Love write -“Most cases present dramatically 2-5 days after operation but, very rarely, the onset is delayed for 2-3 weeks or a patient with marked hypocalcemia is asymptomatic.”
  • One shoudn’t be confused with laryngomalacia. This is not congenital laryngomalacia which occurs in the newborn. This laryngomalacia is softening of the larynx and trachea due to continuous pressure on it by a large goitre. Removal of the goitre causes collapse and kinking of the larynx and trachea leading to airway obstruction.

Q. 12

Which of the following will not lead to respiratory distress after Thyroid Surgery –

 A

Laryngomalacia

 B

Bilateral recurrent laryngeal nerve injury

 C

Hypocalcemia

 D

None

Q. 12

Which of the following will not lead to respiratory distress after Thyroid Surgery –

 A

Laryngomalacia

 B

Bilateral recurrent laryngeal nerve injury

 C

Hypocalcemia

 D

None

Ans. D

Explanation:

Ans is None 

  • All the given conditions are able to cause resp. distress.
  • Endocrine surgery of Head & Neck writes
  • “The reason for airway compromise include :

bilateral recurrent laryngeal nerve injury

tracheal malacia from longstanding tracheal compression caused by a large thyroid mass

subglottic edema from laryngeal involvement with tumor,

tracheal invasion by tumor

post-op hemorrhage or hematoma.”

Hypocalcemia can also cause stridor by causing laryngeal spasm 


Q. 13

Vocal cord palsy in thyroid surgery is due to injury to‑

 A

Superficial laryngeal nerve

 B

Recurrent laryngeal nerve

 C

Ansa cervicalis

 D

Vagus nerve

Q. 13

Vocal cord palsy in thyroid surgery is due to injury to‑

 A

Superficial laryngeal nerve

 B

Recurrent laryngeal nerve

 C

Ansa cervicalis

 D

Vagus nerve

Ans. B

Explanation:

Ans. is ‘b’ i.e., Recurrent laryngeal nerve 


Q. 14

Hoarseness secondary to bronchogenic carcinoma is usually due to extension of the tumour into ‑

 A

Vocal cord

 B

Superior laryngeal nerve

 C

Left recurrent laryngeal nerve

 D

Right vagus nerve

Q. 14

Hoarseness secondary to bronchogenic carcinoma is usually due to extension of the tumour into ‑

 A

Vocal cord

 B

Superior laryngeal nerve

 C

Left recurrent laryngeal nerve

 D

Right vagus nerve

Ans. C

Explanation:

Ans. is ‘c’ i.e., Left recurrent laryngeal nerve


Q. 15

A patient met with recurrent laryngeal nerve palsy while undergoing thyroid surgery. Which of the following muscles of larynx is/are affected?

 A

Posterior crioarytenoid

 B

Lateral cricoarytenoid

 C

Thyroarytenoid

 D

All

Q. 15

A patient met with recurrent laryngeal nerve palsy while undergoing thyroid surgery. Which of the following muscles of larynx is/are affected?

 A

Posterior crioarytenoid

 B

Lateral cricoarytenoid

 C

Thyroarytenoid

 D

All

Ans. D

Explanation:

 

All muscles which move the vocal cord (abductors, adductors or tensors) are supplied by the recurrent laryngeal nerve except the cricothyroid muscle which is supplied by external laryngeal nerve (a branch of superior laryngeal nerve).



Q. 16

Right sided vocal cord palsy seen in:

 A

Larynx carcinoma

 B

Aortic aneurysm

 C

Mediastinal lymphadenopathy

 D

Right vocal nodule

Q. 16

Right sided vocal cord palsy seen in:

 A

Larynx carcinoma

 B

Aortic aneurysm

 C

Mediastinal lymphadenopathy

 D

Right vocal nodule

Ans. A

Explanation:

 

  • Lt RLN.: Arises from vagus in the mediastinum at the level of arch of aorta loops around it and then ascends into the neck.
  • Rt. RLN: Arises from vagus at the level of subclavian artery, hooks around it and then ascends up.

So, any mediastinal causes viz mediastinal lymphadenopathy and aortic aneurysm would parlyse Lt. RLN. only

Vocal nodule does not cause vocal cord palsy.

Laryngeal carcinoma especially glottic can cause U/L or B/L Vocal Cord paralysis – Conn’s Current Theory



Q. 17

Bilateral (B/I) recurrent laryngeal nerve palsy is/ are caused by:

 A

Thyroid surgery

 B

Thyroid malignancy

 C

Aneurysm of arch of aorta

 D

a and b

Q. 17

Bilateral (B/I) recurrent laryngeal nerve palsy is/ are caused by:

 A

Thyroid surgery

 B

Thyroid malignancy

 C

Aneurysm of arch of aorta

 D

a and b

Ans. D

Explanation:

Q. 18

Cause of B/L Recurrent laryngeal nerve palsy is/are: 

 A

Thyroid Ca

 B

Thyroid Surgery

 C

Bronchogenic Ca

 D

a and b

Q. 18

Cause of B/L Recurrent laryngeal nerve palsy is/are: 

 A

Thyroid Ca

 B

Thyroid Surgery

 C

Bronchogenic Ca

 D

a and b

Ans. D

Explanation:

Q. 19

Bilateral recurrent laryngeal nerve palsy is seen in: 

 A

Thyroidectomy

 B

Carcinoma thyroid

 C

Cancer cervical oesophagus

 D

All of the above

Q. 19

Bilateral recurrent laryngeal nerve palsy is seen in: 

 A

Thyroidectomy

 B

Carcinoma thyroid

 C

Cancer cervical oesophagus

 D

All of the above

Ans. D

Explanation:

 

Causes of bilateral recurrent laryngeal nerve palsy are:

  • Idiopathic
  • Post thyroid surgery
  • Thyroid malignancy
  • Carcinoma of cervical part of esophagus
  • Cervical Lymphadenopathy

Peripheral neuritis causes high vagal palsy which leads to both superior as well as recurrent laryngeal nerve palsy i.e. bilateral complete palsy. 


Q. 20

Most common cause of B/L recurrent laryngeal paralysis: 

 A

Thyroid surgery

 B

Cancer cervical oesophagus

 C

Blow from nasal cavity

 D

Thyroid cancer

Q. 20

Most common cause of B/L recurrent laryngeal paralysis: 

 A

Thyroid surgery

 B

Cancer cervical oesophagus

 C

Blow from nasal cavity

 D

Thyroid cancer

Ans. A

Explanation:

Q. 21

Which one of the following lesions of vocal cord is dangerous to life:

 A

Bilateral adductor paralysis

 B

Bilateral abductor paralysis

 C

Combined paralysis of left side superior and recurrent laryngeal nerve

 D

Superior laryngeal nerve paralysis

Q. 21

Which one of the following lesions of vocal cord is dangerous to life:

 A

Bilateral adductor paralysis

 B

Bilateral abductor paralysis

 C

Combined paralysis of left side superior and recurrent laryngeal nerve

 D

Superior laryngeal nerve paralysis

Ans. B

Explanation:

Ans. is b i.e. bilateral abductor paralysis

  • Most dangerous lesion of vocal cords is bilateral abductor paralysis (Bilateral RLN palsy).
  • This is because recurrent laryngeal nerve palsy will lead to paralysis of all laryngeal muscles except the cricothyroid muscle (as it is supplied by superior laryngeal nerve). The cricothyroid muscle is an adductor & therefore this will leave both the cords in median or paramedian position thus endangering proper airway, leading to stridor and dyspnoea.



Q. 22

In complete bilateral palsy of recurrent laryngeal nerves, there is:

 A

Complete loss of speech with stridor and dyspnea

 B

Complete loss of speech but not difficulty in breathing

 C

Preservation of speech with severe stridor and dyspnea

 D

Preservation of speech and not difficulty in breathin

Q. 22

In complete bilateral palsy of recurrent laryngeal nerves, there is:

 A

Complete loss of speech with stridor and dyspnea

 B

Complete loss of speech but not difficulty in breathing

 C

Preservation of speech with severe stridor and dyspnea

 D

Preservation of speech and not difficulty in breathin

Ans. C

Explanation:

Ans. is c i.e. Preservation of speech with severe stridor and dyspnea


Q. 23

The voice in a patient with bilateral abductor paralysis of larynx is:

 A

Puberuophonia

 B

Phonasthenia

 C

Dysphonia plicae ventricularis

 D

Normal or good voice

Q. 23

The voice in a patient with bilateral abductor paralysis of larynx is:

 A

Puberuophonia

 B

Phonasthenia

 C

Dysphonia plicae ventricularis

 D

Normal or good voice

Ans. D

Explanation:

Ans. is d i.e. normal or good voice

Management

  • Lateralization of cord by arytenoidectomy, endoscopic surgery, thyroplasty type II, cordectomy
  • In emergency cases -Tracheostomy may be required

Also know

  • Generally patients with bilateral recurrent laryngeal nerve palsy have a recent history of thyroid surgery or rarely an advanced malignant thyroid tumor.
  • Most common presentation-Development of stridor following URI
  • Since the voice of the patient is normal\it is diagnosed very late.

Q. 24

Injury to superior laryngeal nerve causes:

 A

Hoarseness

 B

Paralysis of vocal cords

 C

No effect

 D

Loss of timbre of voice

Q. 24

Injury to superior laryngeal nerve causes:

 A

Hoarseness

 B

Paralysis of vocal cords

 C

No effect

 D

Loss of timbre of voice

Ans. D

Explanation:

Ans. is d e. Loss of timbre of voice

Paralysis of Superior Laryngeal Nerve -causes paralysis of cricothyroid muscle which is a tensor of vocal cord.

Clinical Features

  • Voice is weak and pitch cannot be raised.
  • U/L Anaesthesia of larynx above the level of vocal cords causing occasional aspiration.



Q. 25

Paralysis of recurrent laryngeal nerve true is:

 A

Common in (Lt) side

 B

50% idiopathic

 C

Cord will be laterally

 D

Speech therapy given

Q. 25

Paralysis of recurrent laryngeal nerve true is:

 A

Common in (Lt) side

 B

50% idiopathic

 C

Cord will be laterally

 D

Speech therapy given

Ans. A

Explanation:

Ans. is a i.e. Common in (left) side

Unilateral Recurrent Laryngeal Nerve Palsy

  • More common on left side than right side because of the longer and more convoluted course of the left recurrent laryngeal nerve (Rt side is involved only in 3-30% cases) (i.e. option a is correct)
  • Most unilateral vocal cord paralysis are secondary to surgery (i.e. option b is incorrect)
  • Unilateral injury to recurrent laryngeal nerve leads to ipsilateral paralysis of all intrinsic muscles except cricothyroid (which is an adductor of vocal cord). The vocal cord thus assumes a median or paramedian position which does not move laterally on deep inspiration (i.e. option c is incorrect)

Clinical Features

  • Asymptomatic in 1 /3rdcases
  • In rest of the patients there may be some voice problem i.e. Dysphonia – the voice is hoarse & becomes weak with use. This gradually improves with time due to compensation by the healthy cord which crosses the midline to meet the paralysed one. Generally no speech therapy is required (i.e. option d is incorrect).



Q. 26

The voice is not affected in:

 A

Unilateral abductor palsy

 B

Unilateral adductor palsy

 C

B/L superior laryngeal palsy

 D

Total adductor palsy

Q. 26

The voice is not affected in:

 A

Unilateral abductor palsy

 B

Unilateral adductor palsy

 C

B/L superior laryngeal palsy

 D

Total adductor palsy

Ans. A

Explanation:

 

In U/L abductor palsy, the affected vocal cord assumes a median or paramedian position. The other is normal so one third patients are asymptomatic while others may have some voice change.


Q. 27

Cadaver like position of vocal cords is seen in

 A

Both superior laryngeal nerve palsy

 B

Both recurrent laryngeal nerve palsy

 C

Both external laryngeal nerve palsy

 D

Both internal laryngeal nerve palsy

Q. 27

Cadaver like position of vocal cords is seen in

 A

Both superior laryngeal nerve palsy

 B

Both recurrent laryngeal nerve palsy

 C

Both external laryngeal nerve palsy

 D

Both internal laryngeal nerve palsy

Ans. B

Explanation:

Recurrent Laryngeal Nerve paralysis:

If both recurrent laryngeal nerves are interrupted, the vocal cords lie in a cadaveric position in between abduction and adduction and phonation is completely lost.

When only one recurrent laryngeal nerve is affected, the opposite vocal cord compensates for it and phonation is possible but there is hoarseness of voice

Superior Laryngeal Nerve paralysis

It divides into external and internal laryngeal nerves. External laryngeal nerve supplies cricothyroid and inferior constrictor and internal laryngeal nerve supplies mucous membrane of the larynx upto the level of vocal folds:

  • Asymmetric vocal cord tension
  • Produces diplophonia
  • Loss of vocal fold tension (lowers pitch of voice)
  • Inaccurate vocal cord apposition
  • Paralysed side slightly shortened and bowed
  • May be depressed below level of normal side
  • Rotation of AP axis of vocal cords
  • Posterior commissure points to side of paralysis
  • Loss of laryngeal sensation and increased risk of aspiration


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