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

Correct. Glottic carcinoma presents early because the vocal cord is the primary phonatory structure — even a small lesion disrupts vibration and produces hoarseness. This early symptom is the key reason glottic carcinoma carries a better prognosis: tumours are detected at an earlier stage. The glottis also has poor lymphatic drainage, meaning nodal metastasis is late.

Glottic carcinoma presents EARLY because any lesion on the vocal cord immediately disrupts phonation, producing hoarseness. Supraglottic carcinoma (epiglottis, aryepiglottic folds) presents LATE because early growth causes only subtle throat discomfort. Critically, the glottis has poor lymphatics — nodal spread is late — which also contributes to its better prognosis. Do NOT credit glottic carcinoma with rich lymphatics.

Hoarseness — not bleeding or immune surveillance — is the early symptom of glottic carcinoma. The glottis has POOR lymphatics (not rich ones), which actually delays nodal spread and contributes to its better prognosis. Supraglottic tumours present late because the supraglottis is a less symptomatically sensitive area in early growth.

Correct. Supraglottic carcinoma arises in the epiglottis and aryepiglottic folds — structures that are not the primary phonatory site. Hoarseness appears only when the tumour invades downward to involve the true vocal cords. This is why supraglottic tumours present late, typically with dysphagia, referred otalgia, and palpable nodal metastases.

Supraglottic carcinoma (epiglottis, aryepiglottic folds, false cords) presents LATE with dysphagia, otalgia and neck mass because these structures are not directly involved in vocal cord vibration. Hoarseness occurs only when the tumour extends inferiorly to involve the true vocal cords. This late-presenting nature leads to advanced stage at diagnosis.

The absence of hoarseness reflects anatomy — supraglottic structures are not the phonatory site. Referred otalgia and cervical nodal spread are classic signs of advanced supraglottic carcinoma. Stridor is not a universal or early feature of supraglottic carcinoma.

Correct. Cricothyroidotomy through the cricothyroid membrane is the emergency surgical airway of choice when intubation fails. The cricothyroid membrane is anterior, superficial, and relatively avascular — it can be accessed rapidly with minimal dissection. Tracheostomy is an elective procedure performed in the operating theatre with adequate lighting, equipment and time.

CRITICAL distinction: Emergency airway = cricothyroidotomy (through the cricothyroid membrane, palpable below the thyroid cartilage notch, above the cricoid). Elective/planned airway = tracheostomy (between the 2nd and 3rd tracheal rings, NOT the 1st — the 1st ring is the lower border of the subglottis; incision here risks subglottic stenosis). Never perform an elective tracheostomy as an emergency procedure.

Tracheostomy is an elective procedure performed between the 2nd and 3rd tracheal rings — it is NOT the correct procedure for an emergency 'can't intubate, can't oxygenate' scenario. The cricothyroid membrane — not the trachea — is the landmark for emergency surgical airway access.

Correct. Vocal cord nodules appear bilaterally at the junction of the anterior and middle thirds of the vocal cords — the point of maximum vibratory impact during phonation. They are the occupational disease of professional voice users (teachers, singers, clergy). Treatment is voice rest and voice therapy; surgery is a last resort.

Vocal cord nodules (singer's nodules): bilateral, symmetric, sessile, at the junction of the anterior and middle thirds (maximum vibratory amplitude point) — a direct consequence of repetitive vocal trauma. Vocal cord polyps are usually unilateral, pedunculated, at the anterior third. Reinke's oedema = diffuse bilateral gelatinous swelling of the entire cord superficial layer, associated with smoking. Papillomata (HPV) = multiple warty lesions, usually children.

The bilateral, symmetric, sessile nature at the anterior-middle junction is the hallmark of vocal cord nodules from vocal trauma. Papillomata are multiple, warty, HPV-associated. Polyps are typically unilateral and pedunculated. Reinke's oedema is diffuse bilateral and strongly linked to smoking.

Correct. Standard tracheostomy is performed between the 2nd and 3rd tracheal rings. This position avoids two critical dangers: (1) too high — at the 1st ring or cricoid — risks subglottic stenosis from pressure on the subglottis; (2) too low — below the 4th ring — risks catastrophic haemorrhage from the innominate artery, which crosses the trachea anteriorly at a variable but typically low level.

Standard tracheostomy incision is placed between the 2nd and 3rd tracheal rings. Incision above the 2nd ring (at the 1st ring or cricoid) risks subglottic stenosis. Incision below the 4th ring risks haemorrhage from the innominate (brachiocephalic) artery. The cricothyroid membrane level is used for cricothyroidotomy, not tracheostomy.

The correct incision level for tracheostomy is between the 2nd and 3rd tracheal rings. The 1st ring level risks subglottic stenosis. Below the 4th ring risks innominate artery injury. The cricothyroid membrane is the site for cricothyroidotomy — the emergency airway, not elective tracheostomy.

Correct. Laryngomalacia (congenital flaccidity of the supraglottic structures) is the most common cause of congenital stridor in infants. Stridor is inspiratory (supraglottic level), present since the first weeks of life, and worsens with agitation and feeding. The prone position opens the airway by preventing the floppy epiglottis from prolapsing. It resolves spontaneously by 12–18 months in the vast majority.

Laryngomalacia is the COMMONEST cause of stridor in infants: onset in the first weeks of life, high-pitched inspiratory stridor (supraglottic obstruction), worse with crying/feeding/supine, relieved prone, and almost always self-resolving by 12–18 months. Normal feeding and weight gain confirm mild disease. Croup affects older infants (6 months–3 years). Acute epiglottitis presents acutely with high fever and drooling — not since birth.

Croup affects children aged 6 months to 3 years after a viral prodrome — not neonates. Epiglottitis presents acutely with fever, drooling and toxic appearance — not a chronic since-birth history. Subglottic haemangioma is rare and typically presents with biphasic stridor that worsens during the first 6 months of life before involuting.

Correct. Reinke's oedema is an accumulation of fluid in the potential space of Reinke (superficial lamina propria of the vocal cord). It produces diffuse bilateral gelatinous polypoid swelling of both cords — the 'waterlogged' appearance. Smoking is the strongest risk factor. Treatment requires smoking cessation first; surgical microdecortication if voice remains significantly affected.

Reinke's oedema = accumulation of gelatinous fluid in Reinke's space (the superficial lamina propria). Causes: smoking (dominant), voice abuse, hypothyroidism, GORD. Bilateral diffuse 'waterlogged' cords in a smoker. Polyps are discrete unilateral pedunculated lesions. Nodules are bilateral but discrete, small, at the anterior-middle junction.

Bilateral gelatinous diffuse cord swelling in a smoker is Reinke's oedema. Polyps are discrete, usually unilateral, pedunculated lesions. Nodules are bilateral but small and discrete at the anterior-middle junction junction point. Chronic hypertrophic laryngitis causes thickened erythematous mucosa but not the characteristic gelatinous swelling of Reinke's space.

Correct. Persistent hoarseness >3 weeks mandates direct visualisation of the larynx. Indirect laryngoscopy or flexible nasolaryngoscopy is the first investigation — it directly visualises the vocal cords, identifies the lesion, and guides subsequent management. CT and microlaryngoscopy are secondary steps after establishing the clinical diagnosis.

Hoarseness >3 weeks demands laryngoscopy to exclude malignancy. The FIRST investigation is always direct visualisation of the larynx — indirect laryngoscopy (mirror) or flexible nasolaryngoscopy. CT and CXR are secondary investigations after the primary diagnosis is established or if a cause outside the larynx is suspected.

CT and CXR are important secondary investigations but are NOT the first step — laryngoscopy provides direct visualisation of the larynx, which is the primary organ of interest. Microlaryngoscopy under GA is performed when the initial laryngoscopy identifies a lesion requiring biopsy or surgical treatment.

Correct. Biphasic stridor indicates obstruction at the glottic or subglottic level. At this level, the obstruction is sufficiently rigid and narrow to impede airflow in both directions. This is a critical sign indicating severe airway narrowing requiring urgent management. Inspiratory stridor alone implies a supraglottic cause; expiratory stridor alone implies intrathoracic tracheal obstruction.

Phase of stridor localises the obstruction: Inspiratory = supraglottis; Biphasic (inspiratory + expiratory) = glottis or subglottis; Expiratory = intrathoracic or infraglottic trachea. Biphasic stridor indicates a fixed narrow lumen at the glottic or subglottic level that obstructs both the inward and outward airflow.

Stridor phase localises obstruction: inspiratory = supraglottis; biphasic = glottis/subglottis; expiratory = infraglottic trachea or bronchi. Biphasic stridor is always a serious sign demanding urgent assessment.

Correct. A fresh tracheostomy stoma (under 7 days) is an emergency when the tube dislodges because the tract is not yet epithelialised and can collapse. Blindly re-inserting the tube risks creating a false passage. The safe sequence is: call for senior help immediately, maintain oxygenation with a facemask over the nose and mouth (upper airway is often still patent), and allow experienced personnel to safely re-intubate either orally or via the stoma.

Tracheostomy tube dislodgement in a FRESH stoma (within 7 days) is a life-threatening emergency: the tract has not yet matured, blind reinsertion risks creating a false passage. The immediate priority is (1) call for help, (2) oxygenate via facemask over the mouth and nose (or stoma), and (3) await experienced assistance for safe reinsertion or oral intubation. Never blindly force the tube back into a fresh stoma.

Blind reinsertion into a fresh stoma is dangerous — the tract is not mature and false passage risks subcutaneous emphysema, haemorrhage or complete airway loss. Cricothyroidotomy is not indicated since the patient already has a tracheostomy stoma that can serve as an airway with expert guidance.