"Laryngology & Airway" — Practice

Question 1

Biphasic stridor in a child most likely indicates obstruction at the

Accepted Answer

C

Question 2

Injury to the external branch of the superior laryngeal nerve produces

Accepted Answer

B

Question 3

Two days after total thyroidectomy a patient has stridor at rest but a clear, strong voice. What has happened and what is the priority?

Accepted Answer

Bilateral recurrent laryngeal nerve palsy. Both cords lie close to the midline, so they approximate well enough for phonation and the voice sounds deceptively normal, while only a slit remains for airflow.

The priority is the airway rather than the voice, and the patient may need reintubation or tracheostomy. The trap is that a good voice feels reassuring, when in fact preservation of voice is characteristic of the bilateral palsy. Unilateral palsy gives the opposite picture: a breathy weak voice with aspiration of thin liquids but a safe airway.

Question 4

A 4-year-old has inspiratory stridor, drooling and high fever, sitting forward and refusing to lie down. A colleague reaches for a tongue depressor. Comment.

Accepted Answer

Stop. This is acute epiglottitis until proved otherwise, and instrumenting the pharynx or laying the child flat can precipitate complete airway obstruction.

The child should be kept upright and calm with a parent, with no cannulation or throat examination attempted. The correct step is immediate involvement of the most senior anaesthetist and ENT surgeon available, with inspection and intubation performed in theatre with facilities for a surgical airway. Antibiotics follow airway control rather than preceding it.

Question 5

A 35-year-old schoolteacher has six months of hoarseness that worsens through the school day. Laryngoscopy shows symmetrical swellings at the junction of the anterior and middle thirds of both cords. What are they, and why that site?

Accepted Answer

Vocal nodules. The site is diagnostic rather than incidental: the junction of the anterior and middle thirds is the point of maximum impact where the cords strike each other during phonation.

That mechanical explanation predicts both the location and the symmetry, and it fits an occupational voice user with symptoms that worsen through a working day. Treatment is voice therapy and vocal hygiene rather than surgery in the first instance. A unilateral lesion at the same site suggests a polyp, and any asymmetry or irregularity requires closer scrutiny for malignancy.

Question 6

A 62-year-old smoker develops hoarseness. Flexible laryngoscopy shows a normal-looking larynx with an immobile left vocal cord. What is the next investigation and why?

Accepted Answer

Contrast imaging of the neck and chest covering the entire course of the left recurrent laryngeal nerve, from skull base to below the aortic arch.

A palsy with a structurally normal larynx means the lesion lies along the nerve rather than within the larynx. The left nerve loops under the aortic arch and travels a long mediastinal course, which exposes it to bronchogenic carcinoma, mediastinal lymphadenopathy, aortic arch aneurysm, a left atrium enlarged by mitral stenosis and oesophageal carcinoma. In a smoker of this age lung cancer heads the list, and stopping at laryngoscopy would leave the actual disease undiagnosed.

Question 7

A 5-year-old with complete airway obstruction cannot be intubated or oxygenated. Why is cricothyroidotomy the wrong procedure, and what is done instead?

Accepted Answer

Because the cricoid cartilage is the narrowest part of the paediatric airway and the only complete cartilaginous ring in the airway, so incising the cricothyroid membrane risks damaging it and producing subglottic stenosis. Surgical cricothyroidotomy is conventionally avoided below about 12 years.

The alternative is needle cricothyroidotomy with jet insufflation as a temporising measure to oxygenate, followed by a definitive surgical airway or removal of the obstruction under controlled conditions. In adults the anatomy reverses the reasoning: the cricothyroid membrane is superficial, palpable and relatively avascular, which makes it the correct emergency target.

Question 8

A 7-year-old with recurrent respiratory papillomatosis has needed six debulking procedures in two years and now has recurrent airway compromise. A colleague suggests tracheostomy. Comment, and outline the alternatives.

Accepted Answer

Tracheostomy should be avoided if at all possible. It is associated with seeding of papillomas distally into the tracheobronchial tree, which converts a laryngeal disease with a difficult but localised course into a pulmonary one that cannot be debulked endoscopically.

The alternatives are continued endoscopic debulking combined with an adjuvant. Bevacizumab, given intralesionally or systemically, is the adjuvant of most current interest, with recent prospective work showing reduced disease burden and improved voice outcomes; cidofovir is the older comparator. Coexisting laryngopharyngeal reflux should be treated, since it is associated with worse disease and more treatment complications. The aetiology is HPV 6 and 11, and HPV vaccination is the only established preventive strategy at population level.

Question 9

A motorcyclist strikes his neck on a wire. He is talking, saturations are normal, but he is hoarse and there is crepitus over the neck. Explain the risk and the management principle.

Accepted Answer

Surgical emphysema after blunt neck trauma means the airway has been breached until proved otherwise, and hoarseness indicates laryngeal involvement. The critical point is that the airway is currently adequate and will not stay that way: oedema and haematoma accumulate over hours, so an airway that permits normal conversation on arrival can close later.

The management principle is therefore that the decision to secure the airway is made early and electively rather than reactively in extremis. Blind or repeated intubation attempts risk converting a partial laryngeal disruption into a complete one by passing a tube through a false passage, so where disruption is suspected a tracheostomy under local anaesthesia is the safer route. Imaging and laryngoscopy define the injury once the airway is safe.

Practice — "Laryngology & Airway"

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