EN4.40-44 | Larynx Voice and Airway — Graded Quiz

Correct. Glottic carcinoma presents early with hoarseness — the vocal cords are the phonatory structures, so even a small lesion produces voice change. Poor lymphatic drainage means nodal metastasis is late. Supraglottic carcinoma (epiglottis, aryepiglottic folds) presents late with dysphagia and neck nodes because the supraglottis has rich lymphatics and early growth causes only subtle discomfort.

Glottic carcinoma: early hoarseness (vocal cord involvement), poor lymphatics → late nodes, good prognosis. Supraglottic: late presentation with dysphagia, referred otalgia, neck nodes because supraglottic structures are not directly phonatory and have rich lymphatics. This distinction is the single most important prognostic differentiator in laryngeal cancer.

Glottic carcinoma has POOR lymphatics and presents EARLY with hoarseness; supraglottic has RICH lymphatics and presents LATE with neck nodes and dysphagia. These are reversed in option B. Option D confuses rich lymphatics (supraglottic) with early presentation — in fact, rich lymphatics lead to early nodal spread but the primary tumour symptoms are late.

Correct. The cricothyroid membrane is the standard emergency surgical airway landmark for cricothyroidotomy. It lies in the midline between the thyroid cartilage above and the cricoid cartilage below — anterior, superficial, and relatively avascular. This is distinct from elective tracheostomy, which is a planned procedure between the 2nd and 3rd tracheal rings.

Emergency airway = cricothyroidotomy through the cricothyroid membrane (palpable midline depression between the thyroid cartilage below and the cricoid cartilage above). Elective airway = tracheostomy between the 2nd-3rd tracheal rings. These must not be conflated. The thyrohyoid membrane is above the thyroid cartilage — not a safe emergency airway site.

Tracheostomy is an elective procedure — not an emergency crash airway. The thyrohyoid membrane is superior to the thyroid cartilage and is not used for emergency airway access. The correct procedure for a CICO emergency is cricothyroidotomy through the cricothyroid membrane.

Correct. Laryngomalacia (congenital floppy supraglottic cartilage) is the most common cause of stridor in infants, accounting for approximately 75% of congenital laryngeal anomalies. It presents from the first weeks of life with inspiratory stridor, worsens with feeding and crying, and resolves spontaneously by 12–18 months in nearly all cases.

Laryngomalacia is the COMMONEST cause of congenital/neonatal stridor — present from the first weeks of life, inspiratory, intermittent, and self-resolving by 12–18 months. Croup affects children 6 months–3 years after viral URTI. Epiglottitis is an acute febrile emergency, not a since-birth history. Subglottic stenosis is uncommon and usually iatrogenic (post-intubation).

Acute epiglottitis presents acutely with fever and drooling — not a birth-onset history. Croup affects older infants (6 months–3 years) after viral URTI, not neonates. Subglottic stenosis is less common and usually post-intubation in premature neonates.

Correct. Persistent hoarseness for more than 3 weeks is the standard clinical threshold that mandates laryngoscopy to exclude laryngeal carcinoma. This is especially critical in patients over 40 years of age with risk factors such as smoking and alcohol use.

Hoarseness > 3 weeks is the threshold mandating laryngoscopy to exclude laryngeal malignancy (per Dhingra and standard ENT practice). This is the key red-flag threshold. Most infective/inflammatory causes of hoarseness resolve within 1–2 weeks; persistence beyond 3 weeks raises concern for structural or malignant pathology.

1 week is insufficient to distinguish transient infective hoarseness from structural causes. 6 weeks and 3 months are too long — delaying laryngoscopy risks missing early laryngeal malignancy. The accepted clinical threshold is 3 weeks.

Correct. Vocal cord nodules are bilateral, symmetric, sessile lesions at the junction of the anterior and middle thirds — the point of maximum vibratory impact. They develop from repetitive mechanical trauma. Treatment is conservative: voice rest and speech therapy. Surgery is reserved for cases refractory to conservative treatment.

Vocal cord nodules (singer's/teacher's nodules): bilateral, symmetric, sessile, at the anterior-middle third junction (maximum vibratory impact point). Cause = repetitive vocal trauma. Treatment = voice rest + voice therapy (surgery is last resort). NOT HPV-related. Contrast with polyps: unilateral, pedunculated. Contrast with papillomata: HPV-related, warty.

Unilateral pedunculated lesions describe vocal cord polyps, not nodules. HPV-related lesions are papillomata (RRP). Nodules respond to voice therapy and do not primarily require surgical excision.

Correct. Inspiratory stridor localises the obstruction to the supraglottis. During inspiration, negative intrathoracic pressure draws air inward — floppy or obstructed supraglottic structures (epiglottis, aryepiglottic folds) collapse further, producing the characteristic inspiratory noise. This is exactly the mechanism in laryngomalacia.

Stridor phase localises obstruction: Inspiratory = supraglottis (floppy supraglottic structures collapse inward during inspiration); Biphasic = glottis/subglottis (rigid narrow lumen obstructs both phases); Expiratory = infraglottic trachea or bronchi (intrathoracic). This physiological principle is the cornerstone of stridor assessment.

Intrathoracic and bronchial obstruction produces expiratory wheeze or stridor. Glottic/subglottic obstruction produces biphasic stridor. Inspiratory stridor specifically indicates supraglottic obstruction.

Correct. Elective tracheostomy is performed between the 2nd and 3rd tracheal rings. This position avoids subglottic stenosis (if too high) and injury to the innominate artery (if too low). The thyroid isthmus, which overlies the 2nd-4th rings, may need to be divided or retracted during the procedure.

Tracheostomy: incision between 2nd-3rd tracheal rings. Above (1st ring/cricoid) = subglottic stenosis risk. Below (4th-5th rings) = innominate artery haemorrhage risk. The cricoid level is for cricothyroidotomy (emergency), not tracheostomy.

The 1st ring level risks subglottic stenosis. Below the 4th ring risks innominate artery haemorrhage. The cricoid level is used for emergency cricothyroidotomy, not elective tracheostomy.

Correct. The definitive diagnosis of laryngeal or hypopharyngeal carcinoma requires laryngoscopy and biopsy of the primary lesion under general anaesthesia (microlaryngoscopy). FNAC of a neck node may provide cytology but does not establish the primary site, histological type, or staging adequately. Histological diagnosis from the primary tumour is mandatory before treatment planning.

Diagnosis of laryngeal/hypopharyngeal carcinoma requires histological confirmation via biopsy — always from the PRIMARY lesion (laryngoscopy + biopsy), not just FNAC of a neck node. FNAC of a neck node alone is insufficient for definitive diagnosis or treatment planning. CT/PET are for staging after histological diagnosis is established.

FNAC of a neck node confirms nodal metastasis but cannot establish the primary site or tumour histology adequately for definitive management. PET and serology are not the diagnostic step — laryngoscopy with biopsy of the primary lesion is required first.

Correct. The left recurrent laryngeal nerve has a significantly longer intrathoracic course because it loops around the aortic arch in the chest before ascending in the tracheo-oesophageal groove to the larynx. This extended course through the mediastinum makes it vulnerable to compression by mediastinal tumours, lung cancer (left hilar), aortic aneurysm, and lymphadenopathy — explaining the higher frequency of left-sided vocal cord palsy in thoracic disease.

LEFT RLN: branches from vagus at the aortic arch level in the chest, loops under the arch, ascends in the tracheo-oesophageal groove — longer intrathoracic course → more often affected by mediastinal masses, lung apical tumours, aortic aneurysm, lymphadenopathy. RIGHT RLN: loops around the right subclavian artery at the neck base — shorter intrathoracic course. Hence, left VCP is more common from thoracic causes.

It is the LEFT RLN (not the right) that loops around the aortic arch in the chest. The right RLN loops around the right subclavian artery at the base of the neck — its intrathoracic course is shorter, so it is less commonly affected by mediastinal disease. Nerve diameter is not the relevant factor.

Correct. The immediate bedside response to an obstructed tracheostomy is to remove the inner cannula (which can be blocked by secretions or inspissated mucus) and suction the airway. Most modern tracheostomy tubes have a double-cannula design precisely for this purpose. This step is safe, rapid and can be performed by any trained ward staff.

Blocked tracheostomy tube: (1) Remove the inner cannula (most tracheostomy tubes have an inner cannula that can be removed and cleaned/replaced immediately); (2) Suction the airway through the outer tube. If obstruction persists → deflate cuff and change the tube. Removing the entire outer tube without a replacement should only be done by experienced personnel. Oral intubation is not the first step.

Oral intubation is a last resort and requires expertise. Removing the entire outer tube on a fresh stoma is dangerous. Nebulised salbutamol does not address mechanical tube obstruction.