2. Question 1
All of the following muscles are supplied by the recurrent
laryngeal nerve except:
A. Posterior cricoarytenoid
B. Lateral cricoarytenoid
C. Cricothyroid
D. Thyroarytenoid
E. Mylohyoid
3. Question 2
Which virus is implicated in recurrent respiratory
papillomatosis:
A. EBV
B. HPV
C. CMV
D. VZV
E. HIV
4. Question 3
A 37-year old opera singer comes to clinic, complaining of 2-
weeks history of hoarseness which is interfering with her
work. On endoscopy, you see normal vibration of the vocal
cords, but notice thickened areas at the anterior 1/3 of both
cords. The most likely diagnosis is:
A. Vocal cord polyp
B. Vocal cord nodules
C. Vocal cord synechia
D. Vocal cord paralysis
E. Carcinoma of the larynx
5. Question 4
A 5-year old child is brought to A&E by his concerned mother
with high fever and difficulty swallowing. On examination, the
child is sat up on the bed, you notice that stridor, quiet
shallow breathing and drooling. ‘Thumb-print sign’ is seen on
XR. The most likely cause is:
A. Epiglottitis
B. Croup
C. Peritonsillar abscess
D. Retropharygeal abscess
E. Foreign body
6. Question 5
A 17-year old comes to see her GP, presenting with a short
history of mild fever, fatigue and sore throat. She has vomited
once at home today. On examination, there is splenomegaly.
Which of the following treatment should the GP avoid:
A. Clarithromycin
B. Doxycycline
C. Co-trimoxazole
D. Amoxicillin
E. Aciclovir
9. • Cricothyrodectomy
▫ Emergency airway
involves puncturing the
cricothyroid
membrane.
• Larynx skeleton made up of various cartilages:
▫ Thyroid cartilage
▫ Cricoidcartiage (complete ring)
▫ Arytenoid cartilages (pyramid-shaped x2)
10. Anatomy: Endoscopic view
• All muscles of the larynx supplied
by the recurrent laryngeal nerve,
from vagus.
• EXCEPT cricothyroid muscle,
innervated by the external branch
of the superior laryngeal nerve.
• Blood supply: Superior and
inferior thyroid arteries.
RimaGlottidis
11. Function of the normal larynx
• Appearance: Pearly-white true vocal cords, with surrounding
structure being light pink.
• Function: Breathing and phonation.
• Movement: Abducts and adducts against each other, meeting
in the midline on phonation. There should be no gaps!
12. Throat symptoms
• Hoarseness
• Stridor: High-pitched noise, in either inspiration or exhalation,
due to upper airway obstruction.
• Stertor: Heavy snoring inspiratory sound, occuring in coma or
deep sleep, sometimes due to obstruction and upper airways.
• Pain: Not common, even in malignancy, but may be a
prominent feature if pathology is inflammatory in nature,
13. Benign: Nodules
• Causes:Microtrauma, gastric
reflux, repeated URTI.
• Findings: Calluses occurs in
pairs,preventing cords from
meeting in the midline. Hourglass
deformity.
• Most commonly occuring in
anterior 1/3 of vocal cords.
• Common in children and female
patients, singers, teachers.
• Symptoms: Hoarseness, painful
phonation, frequent voice breaks,
reduced vocal range.
• Formed slowly over time.
• Management: Intensive speech
and voice therapy, uncommonly
microlaryngeal surgery.
14. Benign: Polyps
• Causes: Isolated trauma, violent
coughing, screaming, LPR
(Laryngopharyngeal reflux).
• Findings:Single or paired lesions
occuring at phonating margin
(edge) of vocal cord.
• Mostly in adult males.
• Symtpoms: Hoarse, breathy
voice, tiring easily.
• Management: Voice therapy,
voice rest, sometimes surgery.
15. Benign: Cysts
• Causes: Poor draining or blocked
small gland in vocal fold,
preventing drainage. Unknown
whether vocal cord irritation or
excessive voice use contributes.
• Findings:Single or paired lesions,
collection of mucous fluid in sac-
like structures.
• Management: Poor response to
conservative Mx. Surgical
removal, followed by voice rest.
16. Reinke’sOedema
• Aka ‘PolypoidDegeneration’ or
‘PolypoidCorditis’.
• Findings: Enlargement of upper
layer of vocal cord covering,
‘Reinke’s space’, with
accumulation of gelatinous fluid.
• Causes: Smoking, never seen in
non-smokers.
• Symptoms: Lower-pitched voice
due to slower vibrations. SOB.
• Management: Surgery. Smoking
cessation is key, as may reoccure
post-surgery is continued.
• Have some malignant potential.
17. Inflammatory: Laryngitis
• Irritation and swelling of vocal
cords, acute vs. chronic.
• Causes: LPR, infection, smoking
and inhalation of noxious fumes.
• Findings: Swollen cords, resulting
in limited mucosal waves and
incomplete closure. May look dry.
• Management: Seek and treat
underlying course. If persists >2
weeks, consider expert advice.
18. Presbylarynx
• Causes: Thicking of vocal cord muscles and
tissues with aging.
• Findings: Reduced bulk, not meeting in
midline.
• Symptoms: Hoarse, weak, breathy voice.
• Management: Injection of fat or other
material to achieve complete closure.
19. Malignancy: Carcinoma of the Larynx
• Causes: Smoking, alcohol, LPR.
• Classification:Supraglottic, glottic, subglottic.
• Pre-malignant: Leukoplakiaon vocal cords, may
develop into cancer if untreated.
• Symptoms: Horaseness, but may be insidious,
presenting with acute airway obstruction. SOB,
neck lump, blood in spit.
• Management: Surgery, cessation of smoking,
alcohol, anti-reflux medication.
20. Vocal Cord Paralysis
• Causes: Iatrogenic, malignant
invasion.
• Findings: Cord abducted on
ipsilateral side, no
movement/vibration
• Symptoms: Adduction failure
results in weak, breathy voice.
• Management: Voice therapy,
surgery with sialistic block to
displace affect cord medially.
22. Recurrent papillomatosis
• Causes: Associated with HPV,
vertical transmission.
• Symptoms:Wart-like lesions in
respiratory tract, causing
recurrent obstruction.
• Young patients with stridor.
• Managment: No definitive cure,
repeat microdebridement or CO2
laser to manage recurrent
lesions.
23. Infectious mononucleiosis
• Glandular fever (aka ‘kissing disease).
• Causes: Epstein-Barr virus.
• Symptoms: Fever, sore throat, malaise,
sometimes vomiting and petichiae.
• Signs: Lymphadenopathy in posterior
cervical, axillary and inguinal regions.
Splenomegaly.
• Investigations: >50% lymphocytes,
10% with enlarged, typical nuclei,
Monospot test (heterophile antibody
test).
• Differentials: CMV, tonsillitis, flu,
leukaemia, diptheria.
• Management: Symptomatic and
supportive. Generally self-limiting,
• Avoid penicillinsRash.
24. Review: Question 1
All of the following muscles are supplied by the recurrent
laryngeal nerve except:
A. Posterior cricoarytenoid
B. Lateral cricoarytenoid
C. Cricothyroid
D. Thyroarytenoid
E. Mylohyoid
Correct answer: C
25. Review: Question 2
Which virus is implicated the development of recurrent
respiratory papillomatosis:
A. EBV
B. HPV
C. CMV
D. VZV
E. HIV
Correct answer: B
26. Review: Question 3
A 37-year old opera singer comes to clinic, complaining of 2-weeks history of
hoarseness which is interfering with her work. On endoscopy, you see
normal vibration of the vocal cords, but notice thickened areas at the
anterior 1/3 of both cords. The most likely diagnosis is:
A. Vocal cord polyp
B. Vocal cord nodules
C. Vocal cord synechia
D. Vocal cord paralysis
E. Carcinoma of the larynx
Correct answer: B
27. Question 4
A 5-year old child is brought to A&E by his concerned mother with high fever
and difficulty swallowing. On examination, the child is sat up on the bed,
you notice that stridor, quiet shallow breathing and drooling. ‘Thumb-
print sign’ is seen on XR. The most likely cause:
A. Epiglottitis
B. Croup
C. Peritonsillar abscess
D. Retropharygeal abscess
E. Foreign body
Correct answer: A
28. Question 5
A 17-year old comes to see her GP, presenting with a short history of mild
fever, fatigue and sore throat. She has vomited once at home today. On
examination, there is splenomegaly. Which of the following treatment
should the GP avoid:
A. Clarithromycin
B. Doxycycline
C. Co-trimoxazole
D. Amoxicillin
E. Aciclovir
Correct answer: D
29.
30. ‘ Nothing can surpass the ability of the voice for
soulful expression of the human experience.’
