A 60-year-old man who smokes and drinks has had discomfort in the throat, pain on swallowing that radiates to the right ear and a muffled voice for three months. He now has hard nodes on both sides of the neck. Laryngoscopy shows a proliferative growth on the laryngeal surface of the epiglottis; both cords move normally. Why are both sides of the neck involved so early?

The supraglottis has a rich lymphatic network that crosses the midline

Supraglottic tumours drain mainly to the prelaryngeal (Delphian) node

The tumour has spread to the neck along the recurrent laryngeal nerve

The epiglottis has no cartilage to resist tumour spread

A 28-year-old woman from rural Odisha with rheumatic heart disease has breathlessness on exertion and a hoarse voice for three months. She has a loud S1, a low-pitched mid-diastolic rumble at the apex and an opening snap. Laryngoscopy shows a paralysed left vocal cord in the paramedian position, with no laryngeal lesion. What is the most likely mechanism of her hoarseness?

Compression of the left recurrent nerve by an enlarged left atrium and pulmonary artery

Injury to the superior laryngeal nerve by a dilated aortic arch

Infiltration of the nerve by mediastinal tuberculous lymph nodes

Embolic infarction of the left vagal nucleus in the medulla

A 66-year-old man who smokes has had hoarseness for a year and stridor for two weeks. Laryngoscopy shows a growth involving the right vocal cord, the false cord and the subglottis, with a fixed right cord. CT shows destruction through the outer cortex of the thyroid cartilage and a single 2.5 cm right level III node. Biopsy is squamous cell carcinoma. A tracheostomy has been done. What is the most appropriate definitive treatment?

Total laryngectomy with neck dissection and adjuvant radiotherapy

Radical radiotherapy alone with the larynx preserved

Vertical hemilaryngectomy with neck dissection

Transoral laser excision of the growth

A 24-year-old man is brought to casualty after a road traffic accident with severe facial fractures and blood in the mouth. Two attempts at intubation have failed, bag-mask ventilation does not raise his SpO2 above 75%, and a supraglottic airway device does not help. Which structure should be incised to gain emergency airway access?

Third and fourth tracheal rings

Larynx: voice, airway and laryngeal cancer

21 NEET-PG practice questions on Larynx: voice, airway and laryngeal cancer, part of ENT. The first 21 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 60-year-old man who smokes and drinks has had discomfort in the throat, pain on swallowing that radiates to the right ear and a muffled voice for three months. He now has hard nodes on both sides of the neck. Laryngoscopy shows a proliferative growth on the laryngeal surface of the epiglottis; both cords move normally. Why are both sides of the neck involved so early?
1. ASupraglottic tumours drain mainly to the prelaryngeal (Delphian) node
2. BThe supraglottis has a rich lymphatic network that crosses the midline
3. CThe tumour has spread to the neck along the recurrent laryngeal nerve
4. DThe epiglottis has no cartilage to resist tumour spread
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Answer: B · The supraglottis has a rich lymphatic network that crosses the midline
The supraglottic larynx, including the epiglottis, develops from the midline buccopharyngeal primordium and has a rich lymphatic network that drains to both sides, so nodal metastases are common, early and often bilateral. These tumours also present late because they cause only vague throat discomfort, referred otalgia or dysphagia until they are large. Treatment must therefore address both sides of the neck. Glottic tumours differ, with scanty lymphatics and early hoarseness.
- A: The Delphian node receives lymph mainly from the subglottis and glottis, not the epiglottis.
- C: Perineural spread along the recurrent nerve is not how supraglottic tumours reach both sides of the neck.
- D: The epiglottis contains elastic cartilage; the nodal spread is due to its lymphatics.
Question 2 · Hard
A 3-year-old boy with subglottic stenosis after prolonged neonatal ventilation needs an elective tracheostomy. The surgical resident lists four points about the procedure in a child: 1. The trachea is opened by a vertical incision, without removing a window of cartilage. 2. Stay sutures are placed on each side of the tracheal incision. 3. A tracheal window, as in adults, is preferred to make tube changes easier. 4. The first tracheal ring is the preferred site. Which points are correct?
1. A1 and 2 only
2. B2 and 3 only
3. C1, 2, 3 and 4
4. D1, 2 and 4 only
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Answer: A · 1 and 2 only
Points 1 and 2 are correct. In children the trachea is soft and small, so it is opened with a vertical slit through the rings below the first, and no cartilage is removed, because removing cartilage can lead to tracheal collapse or stenosis as the child grows. Stay sutures on either side help reinsert the tube if it slips out before a tract has formed. Point 3 is wrong for the reason above, and point 4 is wrong because cutting the first ring risks damage to the cricoid and worsening subglottic stenosis.
- B: Includes the adult-style window and omits the vertical incision.
- C: Includes both the cartilage window and the first ring, which are wrong in children.
- D: Includes the first tracheal ring, which risks cricoid injury and more stenosis.
Question 3 · Hard
A 28-year-old woman from rural Odisha with rheumatic heart disease has breathlessness on exertion and a hoarse voice for three months. She has a loud S1, a low-pitched mid-diastolic rumble at the apex and an opening snap. Laryngoscopy shows a paralysed left vocal cord in the paramedian position, with no laryngeal lesion. What is the most likely mechanism of her hoarseness?
1. AInjury to the superior laryngeal nerve by a dilated aortic arch
2. BInfiltration of the nerve by mediastinal tuberculous lymph nodes
3. CEmbolic infarction of the left vagal nucleus in the medulla
4. DCompression of the left recurrent nerve by an enlarged left atrium and pulmonary artery
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Answer: D · Compression of the left recurrent nerve by an enlarged left atrium and pulmonary artery
The heart sounds indicate mitral stenosis. A large left atrium, together with a dilated pulmonary artery from pulmonary hypertension, can compress the left recurrent laryngeal nerve where it loops under the arch of the aorta near the ligamentum arteriosum, causing left vocal cord palsy: this is Ortner (cardiovocal) syndrome. The right nerve, which loops round the subclavian artery higher in the neck, is not affected. Relieving the stenosis can improve the voice, and echocardiography is the next investigation for the valve.
- A: Superior laryngeal nerve injury affects pitch, not cord movement, and it does not run near the aortic arch.
- B: Tuberculous nodes can affect the nerve, but the heart findings point to mitral stenosis.
- C: A brainstem infarct would cause other cranial nerve and long-tract signs, not isolated cord palsy.
Question 4 · Hard
A 66-year-old man who smokes has had hoarseness for a year and stridor for two weeks. Laryngoscopy shows a growth involving the right vocal cord, the false cord and the subglottis, with a fixed right cord. CT shows destruction through the outer cortex of the thyroid cartilage and a single 2.5 cm right level III node. Biopsy is squamous cell carcinoma. A tracheostomy has been done. What is the most appropriate definitive treatment?
1. ARadical radiotherapy alone with the larynx preserved
2. BTotal laryngectomy with neck dissection and adjuvant radiotherapy
3. CVertical hemilaryngectomy with neck dissection
4. DTransoral laser excision of the growth
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Answer: B · Total laryngectomy with neck dissection and adjuvant radiotherapy
Erosion through the outer cortex of the thyroid cartilage makes this a T4a tumour, and with one ipsilateral node it is stage IVA disease. Cartilage destruction responds poorly to radiotherapy, and a destroyed larynx rarely gives useful function after it, so primary surgery (total laryngectomy with neck dissection) followed by adjuvant radiotherapy or chemoradiotherapy is preferred. Partial laryngectomy and laser excision are suited only to limited tumours with normal cord mobility and intact cartilage. Before surgery he must be counselled about losing his natural voice and about voice rehabilitation by tracheo-oesophageal puncture and prosthesis, oesophageal speech or an electrolarynx.
- A: Radiotherapy alone controls cartilage-destroying T4a tumours poorly.
- C: Hemilaryngectomy is unsafe with a fixed cord, subglottic spread and cartilage destruction.
- D: Laser excision suits small, superficial glottic tumours, not transglottic disease with cartilage invasion.
Question 5 · Medium
A 24-year-old man is brought to casualty after a road traffic accident with severe facial fractures and blood in the mouth. Two attempts at intubation have failed, bag-mask ventilation does not raise his SpO2 above 75%, and a supraglottic airway device does not help. Which structure should be incised to gain emergency airway access?
1. ACricotracheal ligament
2. BThyrohyoid membrane
3. CThird and fourth tracheal rings
4. DCricothyroid membrane
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Answer: D · Cricothyroid membrane
In a 'cannot intubate, cannot oxygenate' situation, emergency front-of-neck access through the cricothyroid membrane is the quickest and safest route. The membrane lies superficially between the thyroid and cricoid cartilages, is easily felt and has few vessels, so a scalpel-bougie-tube technique can be done in under a minute. The cricothyroidotomy should later be converted to a formal tracheostomy, because a tube left there can damage the cricoid and cause subglottic stenosis. A formal tracheostomy through the tracheal rings takes longer and bleeds more in an emergency.
- A: The cricotracheal ligament lies below the cricoid and is less accessible than the cricothyroid membrane.
- B: The thyrohyoid membrane lies above the vocal cords, so an opening there does not bypass the glottis.
- C: Lower tracheal rings lie deeper, behind the thyroid isthmus, and take too long in a crisis.
Question 6 · Medium
A 34-year-old professional singer had a hemithyroidectomy for a follicular adenoma. After surgery her speaking voice is normal in strength, but she can no longer reach high notes and her voice tires quickly. Laryngoscopy shows both cords moving normally. Injury to which nerve explains this?
1. AInternal branch of the superior laryngeal nerve
2. BAnsa cervicalis
3. CExternal branch of the superior laryngeal nerve
4. DRecurrent laryngeal nerve
Answer and explanation in LearnFree account
Question 7 · Medium
A 35-year-old man on treatment for sputum-positive pulmonary tuberculosis has had painful swallowing and a weak, husky voice for a month. Laryngoscopy shows a pale, swollen interarytenoid region with small ulcers, and a vocal cord with an irregular, nibbled edge. Which part of the larynx is characteristically affected first in this condition?
1. APosterior third, around the interarytenoid area
2. BFree edge of the epiglottis tip
3. CSubglottis below the anterior commissure
4. DAnterior commissure
Answer and explanation in LearnFree account
Question 8 · Medium
A 55-year-old bank manager has a T1a squamous cell carcinoma of the middle third of the right vocal cord with normal mobility and no nodes. He is worried about his voice and his job. The tumour board considers four statements: 1. Nodal metastasis is uncommon at this stage. 2. Radiotherapy alone cures most such tumours while keeping a good voice. 3. Elective neck dissection is routinely needed. 4. Total laryngectomy is the first-line treatment. Which statements are correct?
1. A1, 2, 3 and 4
2. B2 and 4 only
3. C1 and 2 only
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 9 · Easy
A 58-year-old schoolteacher who has smoked bidis for 30 years has had hoarseness for six weeks. Laryngoscopy shows a small ulcerated growth on the middle third of the right vocal cord with normal cord movement, and no neck nodes are felt. Why do cancers at this site seldom spread to the neck nodes early?
1. ALymph from the cords drains straight to the mediastinum
2. BGlottic cancers are usually well differentiated
3. CThe vocal cords have very scanty lymphatics
4. DCartilage completely surrounds the vocal cords
Answer and explanation in LearnFree account
Question 10 · Easy
A 32-year-old primary school teacher has had a husky voice that gets worse by the end of each working day for four months. Laryngoscopy shows small, symmetrical, pale nodules on both vocal cords. At which site on the cords are these lesions characteristically found?
1. APosterior commissure between the arytenoids
2. BJunction of anterior one-third and posterior two-thirds
3. CVocal process of the arytenoid
4. DAnterior commissure of both cords
Answer and explanation in LearnFree account
Question 11 · Medium
A 2-year-old girl has had a runny nose for two days and now has a barking, seal-like cough, a hoarse cry and inspiratory stridor at rest that worsens at night. She is not drooling, her temperature is 38 °C and SpO2 is 95%. A frontal neck X-ray shows tapering of the subglottic airway. What is the most appropriate treatment?
1. ANebulised salbutamol alone
2. BCorticosteroid with nebulised adrenaline
3. CIV ceftriaxone and urgent intubation
4. DBronchoscopy to remove a foreign body
Answer and explanation in LearnFree account
Question 12 · Medium
A 62-year-old man who has smoked for 40 years has had a weak, breathy voice for two months and coughs when he drinks water. Indirect laryngoscopy shows that the left vocal cord does not move and lies in the paramedian position; the right cord is normal and there is no growth in the larynx. Neck examination is normal. What is the best next investigation?
1. ABarium swallow of the oesophagus
2. BCECT from skull base to upper chest
3. CUltrasound of the thyroid gland only
4. DPure tone audiometry
Answer and explanation in LearnFree account
Question 13 · Hard
A 10-week-old girl has noisy breathing that started at about 4 weeks and is getting worse, heard on both inspiration and expiration and worse when she cries. She has a red, raised strawberry-like lesion on her chin and lower lip. Her cry is normal. Laryngoscopy under anaesthesia shows a smooth, compressible, reddish swelling on the left side of the subglottis. Which drug is first-line treatment?
1. ASubcutaneous interferon alfa
2. BOral prednisolone alone
3. CIntralesional bleomycin
4. DOral propranolol
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Question 14 · Easy
A 6-week-old boy has noisy breathing that began a few days after birth. The noise is heard on inspiration, is worse when he cries, feeds or lies on his back, and is quieter when he lies prone. He is feeding and gaining weight well. Flexible laryngoscopy shows an omega-shaped epiglottis with short aryepiglottic folds that are drawn in on inspiration. What is the diagnosis?
1. ABilateral vocal cord palsy
2. BLaryngomalacia
3. CLaryngeal web
4. DSubglottic stenosis
Answer and explanation in LearnFree account
Question 15 · Medium
A 47-year-old woman who has smoked heavily for 25 years has had a low-pitched, husky voice for two years; people on the telephone often mistake her for a man. Laryngoscopy shows smooth, pale, fusiform swellings along the full length of both vocal cords, which flap with breathing. What is the most likely diagnosis?
1. AReinke oedema
2. BVocal cord nodules
3. CLaryngeal papillomatosis
4. DGlottic carcinoma
Answer and explanation in LearnFree account
Question 16 · Medium
A 64-year-old farmer from Tamil Nadu has been hoarse for five months. Direct laryngoscopy shows a squamous cell carcinoma involving the left vocal cord and extending to the anterior commissure; the left cord is fixed. The tumour does not breach the thyroid cartilage, and no nodes are found on CT. What is the T stage of the tumour (AJCC 8th edition)?
1. AT1b
2. BT4a
3. CT3
4. DT2
Answer and explanation in LearnFree account
Question 17 · Medium
A 4-year-old unvaccinated boy is brought to casualty with high fever for six hours. He sits leaning forward with his chin up and mouth open, drooling, with a muffled voice and soft inspiratory stridor. He looks toxic and does not cough. A portable lateral neck X-ray shows a swollen epiglottis. What is the next best step?
1. AGive nebulised adrenaline and oral dexamethasone
2. BSecure the airway in theatre with a surgeon ready
3. CExamine the throat with a tongue depressor
4. DLie him flat and draw blood for culture first
Answer and explanation in LearnFree account
Question 18 · Medium
A 42-year-old woman had a total thyroidectomy 14 months ago and needed a tracheostomy for stridor soon after. Her voice is fairly good, but every attempt to cork the tube brings back stridor. Repeated laryngoscopy shows both vocal cords fixed close to the midline, with no recovery over the past year. She wants to be free of the tube. Which procedure best meets her aim?
1. AMedialisation thyroplasty of both vocal cords
2. BDecannulation after a course of voice therapy
3. CEndoscopic posterior cordotomy or arytenoidectomy
4. DInjection of filler into both vocal cords
Answer and explanation in LearnFree account
Question 19 · Medium
A 3-year-old girl has had a progressively hoarse cry for six months and now has mild stridor on exertion. Her mother had genital warts during pregnancy. Microlaryngoscopy shows multiple warty, exophytic growths on both vocal cords and the anterior commissure. Which statement about her management is correct?
1. ATracheostomy should be done early to protect the airway
2. BTotal laryngectomy is required once the cords are involved
3. CRepeated debulking is needed, and tracheostomy is avoided where possible
4. DA single wide excision with a margin is usually curative
Answer and explanation in LearnFree account
Question 20 · Medium
A 50-year-old man had a tracheostomy three days ago after a head injury. The nurse finds him restless with SpO2 84%, suprasternal retraction and poor air entry; the suction catheter will not pass beyond a few centimetres down the tube. The neck shows no swelling or crepitus. What is the first action?
1. AIncrease the inspired oxygen to 100%
2. BDeflate the cuff and wait for a doctor
3. COrder an urgent chest X-ray
4. DRemove and clean the inner cannula
Answer and explanation in LearnFree account
Question 21 · Easy
A 45-year-old man in the ICU needs an elective tracheostomy after two weeks of ventilation. The surgeon divides the thyroid isthmus. Through which tracheal rings is the tube usually placed?
1. ACricothyroid membrane
2. BFifth and sixth rings
3. CFirst ring and cricoid
4. DSecond and third rings
Answer and explanation in LearnFree account

Larynx: voice, airway and laryngeal cancer

A 34-year-old professional singer had a hemithyroidectomy for a follicular adenoma. After surgery her speaking voice is normal in strength, but she can no longer reach high notes and her voice tires quickly. Laryngoscopy shows both cords moving normally. Injury to which nerve explains this?

A 32-year-old primary school teacher has had a husky voice that gets worse by the end of each working day for four months. Laryngoscopy shows small, symmetrical, pale nodules on both vocal cords. At which site on the cords are these lesions characteristically found?

A 45-year-old man in the ICU needs an elective tracheostomy after two weeks of ventilation. The surgeon divides the thyroid isthmus. Through which tracheal rings is the tube usually placed?