Endocrine Surgery

Endocrine Surgery US Medical PG Question 1: A 50-year-old woman comes to the physician because of palpitations and irritability. Over the past 4 months, she has had several episodes of heart racing and skipping beats that lasted between 30 seconds and several hours. She has also been arguing with her husband more, often about the temperature being too warm. The patient has also lost 8.8-kg (19.4-lb) over the past 4 months, despite being less strict with her diet. She has mild asthma treated with inhaled bronchodilators. Her pulse is 102/min and blood pressure is 148/98 mm Hg. On physical examination, the skin is warm and moist. A mass is palpated in the anterior neck area. On laboratory studies, thyroid stimulating hormone is undetectable and there are antibodies against the thyrotropin-receptor. Thyroid scintigraphy shows diffusely increased iodine uptake. Two weeks later, a single oral dose of radioactive iodine is administered. This patient will most likely require which of the following in the long-term?

• A. Propranolol therapy
• B. Near-total thyroidectomy
• C. L-thyroxine therapy (Correct Answer)
• D. Methimazole therapy
• E. Estrogen replacement therapy

Endocrine Surgery Explanation: * ***L-thyroxine therapy*** * Radioactive iodine ablation for **Graves' disease** often leads to **permanent hypothyroidism**, necessitating **lifelong thyroid hormone replacement** with levothyroxine. * The patient presents with classic **hyperthyroidism** symptoms (palpitations, irritability, weight loss, heat intolerance, warm/moist skin, goiter, undetectable TSH, positive **TSH receptor antibodies**, diffuse uptake on scintigraphy), treated with radioactive iodine. * *Propranolol therapy* * Propranolol is a **beta-blocker** used for symptomatic relief of hyperthyroidism, particularly palpitations and tremors. * It does **not treat the underlying cause** of hyperthyroidism or subsequent hypothyroidism, and therefore is not a long-term solution after successful radioactive iodine therapy. * *Near-total thyroidectomy* * A near-total thyroidectomy is a surgical option for hyperthyroidism, especially in cases of very large goiters, contraindications to radioactive iodine, or malignancy. * While it also often leads to **hypothyroidism** requiring long-term L-thyroxine, it was **not the chosen treatment modality** in this scenario (radioactive iodine was administered). * *Methimazole therapy* * Methimazole is an **antithyroid drug** used to decrease thyroid hormone synthesis in hyperthyroidism. * It is used as a **primary treatment for hyperthyroidism** or as preparation for definitive therapy like radioactive iodine or surgery; it is not a long-term treatment after successful radioactive iodine ablation has induced hypothyroidism. * *Estrogen replacement therapy* * Estrogen replacement therapy is used for symptoms of **menopause** or to prevent osteoporosis, but it has no direct role in the management of thyroid disorders. * The patient's symptoms are clearly indicative of a **thyroid pathology**, not primarily menopausal symptoms.

Endocrine Surgery US Medical PG Question 2: A 31-year-old man comes to the physician because of worsening abdominal pain, an inability to concentrate at work, and a general lack of motivation over the past several months. He has a history of spontaneous passage of two kidney stones. His father and uncle underwent thyroidectomy before the age of 35 for thyroid cancer. Physical examination shows diffuse tenderness over the abdomen. Serum studies show: Na+ 142 mEq/L K+ 3.7 mEq/L Glucose 131 mg/dL Ca2+ 12.3 mg/dL Albumin 4.1 g/dL Parathyroid hormone 850 pg/mL Further evaluation is most likely to show elevated levels of which of the following?

• A. Serum aldosterone to renin ratio
• B. Serum prolactin
• C. Urine metanephrines (Correct Answer)
• D. Urine 5-hydroxyindoleacetic acid
• E. Midnight salivary cortisol

Endocrine Surgery Explanation: ***Urine metanephrines*** - The patient's presentation with **hypercalcemia** (Ca2+ 12.3 mg/dL) and **elevated PTH** (850 pg/mL) indicates **hyperparathyroidism**. - The family history of **thyroidectomy for thyroid cancer before age 35** (medullary thyroid cancer) along with hyperparathyroidism points towards **Multiple Endocrine Neoplasia type 2 (MEN2)**. MEN2 syndromes often include **pheochromocytoma**, which is diagnosed by elevated **urine metanephrines**. *Serum aldosterone to renin ratio* - This ratio is used to screen for **primary hyperaldosteronism**, which presents with **hypertension and hypokalemia**. - The patient's blood pressure is not mentioned as elevated, and his **potassium (3.7 mEq/L) is within normal limits**, making primary hyperaldosteronism less likely. *Serum prolactin* - Elevated serum prolactin levels indicate **hyperprolactinemia**, which is a feature of **MEN1 (Multiple Endocrine Neoplasia type 1)**. - While MEN1 also includes hyperparathyroidism, the family history of **early-onset thyroid cancer** (suggesting medullary thyroid cancer, not typically seen in MEN1) points more strongly to MEN2. *Urine 5-hydroxyindoleacetic acid* - Elevated levels of **5-HIAA in urine** are indicative of a **carcinoid tumor**, which secretes serotonin. - Carcinoid tumors are not typically associated with the constellation of symptoms and family history presented, particularly hyperparathyroidism and early-onset medullary thyroid cancer. *Midnight salivary cortisol* - This test is used to diagnose **Cushing's syndrome**, which is characterized by elevated cortisol levels and symptoms like central obesity, moon facies, and striae. - The patient's symptoms are not consistent with Cushing's syndrome, and the laboratory findings (hypercalcemia, elevated PTH) point to a different endocrine disorder.

Endocrine Surgery US Medical PG Question 3: A 40-year-old woman comes to the physician because of a 3-month history of a lump on her neck. The lump is mildly painful. She appears healthy. Examination shows a swelling on the left side of her neck that moves on swallowing. Cardiopulmonary examination shows no abnormalities. Her TSH is 3.6 μU/mL. Ultrasound shows a 4.0-cm (1.6-in) hypoechoic mass in the left thyroid lobe. Fine-needle aspiration of the mass shows neoplastic follicular cells. Molecular analysis of the aspirate shows a mutation in the RAS gene. Which of the following is the most appropriate next step in management?

• A. Radioiodine therapy
• B. External beam radiation
• C. Total thyroidectomy
• D. Thyroid lobectomy (Correct Answer)
• E. Watchful waiting

Endocrine Surgery Explanation: ***Thyroid lobectomy*** - A **thyroid lobectomy** is appropriate for a **solitary thyroid nodule** with suspicious features (hypoechoic, neoplastic follicular cells, **RAS mutation**) and a size of 4.0 cm, as it allows for pathological diagnosis and treatment while preserving the other lobe. - The **RAS mutation** indicates a moderate risk of malignancy, and for a unilateral tumor of this size, lobectomy is often preferred over total thyroidectomy as it minimizes the risk of **hypoparathyroidism** and the need for lifelong thyroid hormone replacement. *Radioiodine therapy* - This therapy is primarily used as an **adjunctive treatment** after surgical removal of thyroid cancer, especially for **metastatic disease** or **large residual tumors**, not as a primary treatment for a localized tumor before surgery. - It is also typically reserved for **differentiated thyroid cancers** (papillary, follicular) that have demonstrated uptake, and surgical removal is the initial step for diagnosis and treatment. *External beam radiation* - **External beam radiation** is generally reserved for **advanced, inoperable thyroid cancers** or for cases with **extracapsular invasion** or **distant metastases** that are not amenable to radioiodine therapy. - It carries significant side effects and is not a first-line treatment for an early-stage, localized thyroid nodule. *Total thyroidectomy* - **Total thyroidectomy** is indicated for larger thyroid cancers (>4 cm), bilateral disease, or aggressive histological subtypes. - Given the patient's **unilateral tumor** with a **RAS mutation** (which signifies moderate risk), a thyroid lobectomy is appropriate as the initial surgical approach, with total thyroidectomy reserved if final pathology shows aggressive features. *Watchful waiting* - **Watchful waiting** is inappropriate given the presence of **neoplastic follicular cells** and a **RAS mutation**, as these findings indicate a significant risk of malignancy. - The nodule size of 4.0 cm and molecular findings warrant surgical intervention for definitive diagnosis and treatment rather than observation.

Endocrine Surgery US Medical PG Question 4: Immediately after undergoing a right total knee replacement, a 69-year-old woman has severe abdominal pain, non-bloody emesis, and confusion. She has a history of Hashimoto thyroiditis that is well-controlled with levothyroxine and hyperlipidemia that is controlled by diet. She underwent bunion removal surgery from her right foot 10 years ago. Her temperature is 39°C (102.2°F), pulse is 120/min, and blood pressure is 60/30 mm Hg. Abdominal examination shows a diffusely tender abdomen with normal bowel sounds. She is confused and oriented to person but not place or time. Laboratory studies are pending. Which of the following is the most appropriate next step in the management of this patient?

• A. High-dose hydrocortisone
• B. Exploratory laparotomy
• C. CT angiogram of the abdomen
• D. Noncontrast CT of the head
• E. Intravenous isotonic saline infusion (Correct Answer)

Endocrine Surgery Explanation: ***Intravenous isotonic saline infusion*** - The patient presents with **shock** (BP 60/30 mm Hg, pulse 120/min, confusion), which is immediately life-threatening and requires urgent intervention. - **IV fluid resuscitation** is the **first priority** in any shock state to restore intravascular volume, improve tissue perfusion, and stabilize hemodynamics. - While this patient has features concerning for **acute adrenal crisis** (Hashimoto thyroiditis with possible polyglandular autoimmune syndrome, post-surgical stress, fever, hypotension, confusion), **fluid resuscitation must be initiated immediately** before or concurrent with other therapies. - In practice, **high-dose hydrocortisone should be given simultaneously** with fluids, but restoring circulating volume is the foundational first step. *High-dose hydrocortisone* - This patient has **Hashimoto thyroiditis** and presents with shock after major surgery (a known precipitant), raising strong suspicion for **acute adrenal crisis**. - Patients with autoimmune thyroid disease can have concurrent **autoimmune adrenal insufficiency** (Schmidt syndrome/APS-2). - **Hydrocortisone is critical** and should be given immediately (typically 100 mg IV), but **not before addressing the shock state** with fluid resuscitation. - This would be the appropriate **second step** or given concurrently with fluids. *Exploratory laparotomy* - While the patient has **severe abdominal pain** and **diffuse tenderness**, the overall presentation (fever, hypotension, post-op state) suggests **medical shock** rather than a surgical emergency. - **Normal bowel sounds** make mechanical obstruction or perforation less likely. - Surgery is inappropriate until the patient is hemodynamically stabilized and a surgical cause is confirmed. *CT angiogram of the abdomen* - This could evaluate for **mesenteric ischemia**, but the patient is **too unstable** for imaging. - The clinical picture better fits **adrenal crisis** or **septic shock** rather than vascular catastrophe. - **Delaying resuscitation** for imaging in a patient with severe hypotension would be harmful. *Noncontrast CT of the head* - The patient's **confusion** is most likely due to **hypoperfusion** and **shock** rather than a primary intracranial process. - **Altered mental status** is a common manifestation of shock and adrenal crisis. - Cerebral perfusion depends on adequate systemic blood pressure, making **circulatory stabilization the priority**.

Endocrine Surgery US Medical PG Question 5: A 20-year-old woman visits the clinic for her annual physical examination. She does not have any complaints during this visit. The past medical history is insignificant. She follows a healthy lifestyle with a balanced diet and moderate exercise schedule. She does not smoke or drink alcohol. She does not take any medications currently. The family history is significant for her grandfather and uncle who had their parathyroid glands removed. The vital signs include: blood pressure:122/88 mm Hg, pulse 88/min, respirations 17/min, and temperature 36.7°C (98.0°F). The physical exam is within normal limits. The lab test results are as follows: Blood Urea Nitrogen 12 mg/dL Serum Creatinine 1.1 mg/dL Serum Glucose (Random) 88 mg/dL Serum chloride 107 mmol/L Serum potassium 4.5 mEq/L Serum sodium 140 mEq/L Serum calcium 14.5 mg/dL Serum albumin 4.4 gm/dL Parathyroid Hormone (PTH) 70 pg/mL (Normal: 10-65 pg/mL) 24-Hr urinary calcium 85 mg/day (Normal: 100–300 mg/day) Which of the following is the next best step in the management of this patient?

• A. No treatment is necessary (Correct Answer)
• B. Start IV fluids to keep her hydrated
• C. Start her on pamidronate
• D. Give glucocorticoids
• E. Parathyroidectomy

Endocrine Surgery Explanation: ***No treatment is necessary*** - This patient has **familial hypocalciuric hypercalcemia (FHH)**, a benign autosomal dominant condition caused by inactivating mutations in the calcium-sensing receptor (CaSR). - The key diagnostic triad is: **elevated serum calcium** (14.5 mg/dL), **mildly elevated or inappropriately normal PTH** (70 pg/mL), and **LOW 24-hour urinary calcium** (<100 mg/day). - The family history of parathyroid surgery in relatives suggests they may have been misdiagnosed with primary hyperparathyroidism. - **FHH is a benign condition that requires no treatment**. Patients are typically asymptomatic and do not develop complications of hypercalcemia. - The calcium-creatinine clearance ratio (CCCR) is typically <0.01 in FHH, which helps distinguish it from primary hyperparathyroidism (CCCR >0.02). *Parathyroidectomy* - **Parathyroidectomy is contraindicated in FHH** and is a common error in management. - Surgery does not correct the hypercalcemia in FHH because the defect is in the calcium-sensing receptor throughout the body, not in the parathyroid glands. - Parathyroidectomy can lead to **permanent hypoparathyroidism** without resolving the underlying condition. - Surgery is indicated for **primary hyperparathyroidism**, which differs from FHH by having normal or elevated urinary calcium excretion. *Start IV fluids to keep her hydrated* - IV fluids are used for **acute symptomatic hypercalcemia** or hypercalcemic crisis. - This patient is **asymptomatic** with stable vital signs and does not require acute intervention. - Fluids do not address the underlying pathophysiology of FHH and are unnecessary in this benign condition. *Start her on pamidronate* - Bisphosphonates like pamidronate are used for **hypercalcemia of malignancy** or severe symptomatic primary hyperparathyroidism. - They are **ineffective in FHH** because the hypercalcemia is due to altered calcium sensing, not increased bone resorption. - Pamidronate is not indicated for chronic management of asymptomatic hypercalcemia due to FHH. *Give glucocorticoids* - Glucocorticoids treat hypercalcemia from **granulomatous diseases** (sarcoidosis), **vitamin D intoxication**, or **hematologic malignancies** (lymphoma, multiple myeloma). - They work by decreasing intestinal calcium absorption and are ineffective in FHH. - This patient's clinical presentation and laboratory findings do not suggest any of these conditions.

Endocrine Surgery US Medical PG Question 6: A 43-year-old male with a history of thyroid cancer status post total thyroidectomy presents to his primary care physician after repeated bouts of headaches. His headaches are preceded by periods of anxiety, palpitations, and sweating. The patient says he is unable to pinpoint any precipitating factors and instead says the events occur without warning. Of note, the patient's father and uncle also have a history of thyroid cancer. On exam his vitals are: T 36.8 HR 87, BP 135/93, RR 14, and O2 Sat 100% on room air. The patient's TSH is within normal limits, and he reports taking his levothyroxine as prescribed. What is the next best step in diagnosing this patient's chief complaint?

• A. 24-hour urine free cortisol
• B. Plasma aldosterone/renin ratio
• C. Abdominal CT scan with and without IV contrast
• D. Plasma fractionated metanephrines (Correct Answer)
• E. High dose dexamethasone suppression test

Endocrine Surgery Explanation: ***Plasma fractionated metanephrines*** - The patient's symptoms of **anxiety, palpitations, sweating, and headaches** occurring in discrete "attacks" are classic for a **pheochromocytoma**, a tumor that secretes catecholamines. - Given the patient's and his family's history of **thyroid cancer**, specifically likely **medullary thyroid cancer** due to the familial link, there is a high suspicion for **Multiple Endocrine Neoplasia type 2 (MEN2)**, which commonly includes pheochromocytoma. **Plasma fractionated metanephrines** are the most sensitive screening test for pheochromocytoma. *24-hour urine free cortisol* - This test is used to detect **Cushing's syndrome**, which involves excessive cortisol production. - Although Cushing's can cause **hypertension**, the paroxysmal symptoms of anxiety, palpitations, and sweating are not typical of Cushing's syndrome. *Plasma aldosterone/renin ratio* - This ratio is used to screen for **primary hyperaldosteronism**, a cause of secondary hypertension. - While the patient has **hypertension (135/93 mm Hg)**, his symptom complex of episodic anxiety, palpitations, and sweating is not characteristic of primary hyperaldosteronism. *Abdominal CT scan with and without IV contrast* - An abdominal CT scan can visualize adrenal masses, but it is typically performed *after* biochemical confirmation of a pheochromocytoma to localize the tumor. - Performing imaging before biochemical testing risks incidentalomas or missing a biochemically active but small tumor, and it is not the most appropriate *next step* in diagnosis given the strong clinical suspicion. *High dose dexamethasone suppression test* - This test is specifically used to differentiate between **Cushing's disease** (pituitary ACTH excess) and other causes of Cushing's syndrome. - The patient's symptoms are not consistent with excessive cortisol production, making this test inappropriate for his chief complaint.

Endocrine Surgery US Medical PG Question 7: A 75-year-old man is referred for thyroidectomy for treatment of thyroid nodules. A portion of the thyroid gland is resected, and the neck is closed with sutures. After awakening from anesthesia, the patient complains of ‘hoarseness’. His vital signs are normal and his incisional pain is minimal. The surgeon realizes he most likely damaged the recurrent laryngeal nerve. Which of the following should the surgeon tell the patient?

• A. "A mistake occurred during the operation, but there was no harm to you."
• B. "We made a mistake during the operation that may have harmed you." (Correct Answer)
• C. "The case took longer than we thought it would, but everything went well."
• D. "A mistake occurred because this hospital has poor operating room protocols."
• E. "The operation was successful and no complications occurred."

Endocrine Surgery Explanation: ***\"We made a mistake during the operation that may have harmed you.\"*** - This statement accurately reflects the situation, acknowledging both the **mistake** and the potential **harm** to the patient (hoarseness due to recurrent laryngeal nerve damage). - Open communication and honesty about medical errors are essential for maintaining **trust** and fulfilling ethical obligations to the patient. *\"A mistake occurred during the operation, but there was no harm to you.\"* - This statement is inaccurate because the patient is experiencing **hoarseness**, which is a sign of harm (recurrent laryngeal nerve damage). - Dismissing the patient's symptom as "no harm" is **dishonest** and undermines trust. *\"The case took longer than we thought it would, but everything went well.\"* - This statement is misleading as it downplays a significant complication (recurrent laryngeal nerve damage) by implying that "everything went well" despite the patient's hoarseness. - It avoids addressing the specific concern and does not acknowledge any **error** or **harm**. *\"A mistake occurred because this hospital has poor operating room protocols.\"* - While a mistake may have occurred, blaming the hospital's protocols is an attempt to deflect personal responsibility and can be seen as unprofessional. - This statement introduces a potentially contentious issue that should be addressed internally rather than with the patient when disclosing the error. *\"The operation was successful and no complications occurred.\"* - This statement is explicitly false, as **hoarseness** due to recurrent laryngeal nerve damage is a direct and recognized **complication** of thyroidectomy. - Making such a claim is unethical and violates the principle of **informed consent** and truthful disclosure.

Endocrine Surgery US Medical PG Question 8: A 27-year-old-man is brought to the emergency department 30 minutes after being involved in a motorcycle accident. He lost control at high speed and was thrown forward onto the handlebars. On arrival, he is alert and responsive. He has abdominal pain and superficial lacerations on his left arm. Vital signs are within normal limits. Examination shows a tender, erythematous area over his epigastrium. The abdomen is soft and non-distended. A CT scan of the abdomen shows no abnormalities. Treatment with analgesics is begun, the lacerations are cleaned and dressed, and the patient is discharged home after 2 hours of observation. Four days later, the patient returns to the emergency department with gradually worsening upper abdominal pain, fever, poor appetite, and vomiting. His pulse is 91/min and blood pressure is 135/82 mm Hg. Which of the following is the most likely diagnosis?

• A. Abdominal compartment syndrome
• B. Aortic dissection
• C. Splenic rupture
• D. Pancreatic ductal injury (Correct Answer)
• E. Diaphragmatic rupture

Endocrine Surgery Explanation: ***Pancreatic ductal injury*** - A forceful impact to the **epigastrium** (e.g., falling onto handlebars) can cause **pancreatic injury**, particularly a **ductal transection**, due to the pancreas being compressed against the vertebral column. - Initial CT scans can be normal because the injury to the **ductal system** takes time to manifest, leading to delayed symptoms like **worsening abdominal pain, fever, vomiting**, and **poor appetite** several days later due to **pancreatitis** or a **pseudocyst** formation. *Abdominal compartment syndrome* - This typically presents with **acute abdominal distension**, increased intra-abdominal pressure, and organ dysfunction (e.g., oliguria, respiratory compromise), which are not described here. - It's an immediate complication of severe trauma or fluid resuscitation, not a delayed presentation like described. *Aortic dissection* - Characterized by **sudden-onset, severe, tearing chest or back pain** and often involves hypertension or Marfan syndrome. - It would manifest immediately with hemodynamic instability and distinct pain, not a delayed presentation of progressive abdominal symptoms. *Splenic rupture* - Often causes **left upper quadrant pain**, **Kehr's sign** (referred shoulder pain), and **hemodynamic instability** due to significant blood loss. - While possible in trauma, a normal initial CT scan makes this less likely, and its symptoms usually appear earlier or are more severe. *Diaphragmatic rupture* - Can present with **dyspnea, shoulder pain**, or signs of **herniated abdominal organs** into the chest. - It causes more immediate respiratory distress or gastrointestinal obstruction symptoms, and the abdominal symptoms described are not typical for this injury.

Endocrine Surgery US Medical PG Question 9: A 62-year-old man comes to the physician for a follow-up examination after having been diagnosed with stage II adenocarcinoma of the left lower lung lobe without evidence of distant metastases 1 week ago following an evaluation for a chronic cough. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for the past 40 years. His current medications include metformin, sitagliptin, and enalapril. He is 177 cm (5 ft 10 in) tall and weighs 65 kg (143 lb); BMI is 20.7 kg/m2. He appears lethargic. Vital signs are within normal limits. Pulse oximetry shows an oxygen saturation of 98%. Examination shows inspiratory wheezing at the left lung base. The remainder of the examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, creatinine, glucose, and liver enzymes are within the reference range. Spirometry shows an FEV1 of 1.6 L. The diffusing lung capacity for carbon monoxide (DLCO) is 66% of predicted. Which of the following is the most appropriate next step in the management of this patient?

• A. Schedule lobectomy (Correct Answer)
• B. Administer cisplatin and vinorelbine
• C. Schedule a wedge resection
• D. Administer cisplatin and etoposide
• E. Radiation therapy

Endocrine Surgery Explanation: ***Schedule lobectomy*** - The patient has **stage II non-small cell lung cancer (adenocarcinoma)** without distant metastases, making surgical resection with **lobectomy** the treatment of choice for curative intent. - While pulmonary function is somewhat impaired (FEV1 and DLCO), his overall status, age, and normal labs suggest he can likely tolerate the procedure. *Administer cisplatin and vinorelbine* - This combination is a common regimen for **adjuvant chemotherapy** following surgical resection in certain stages of NSCLC, or for advanced unresectable disease. - It is not the primary treatment for a resectable stage II cancer; **surgery is preferred for cure**. *Schedule a wedge resection* - A **wedge resection** (sublobar resection) is typically reserved for patients with very small, peripheral tumors or those with severe comorbidities that preclude lobectomy due to poor pulmonary function. - Given the patient's stage II disease and potentially curative intent, a **lobectomy is generally preferred** for better oncologic outcomes. *Administer cisplatin and etoposide* - This chemotherapy regimen is more commonly used for **small cell lung cancer (SCLC)** or for some advanced NSCLC cases, not typically for resectable stage II adenocarcinoma as a primary treatment. - Even if used in NSCLC, it would usually be in the context of advanced disease or as part of a neoadjuvant/adjuvant approach with surgery, not as a standalone initial treatment for resectable disease. *Radiation therapy* - **Radiation therapy** is often used for inoperable tumors, for patients who refuse surgery, or as an adjuvant treatment. - For a resectable stage II NSCLC, **surgery offers the best chance for cure**, making radiation therapy alone less appropriate as the first-line definitive treatment strategy.

Endocrine Surgery US Medical PG Question 10: An obese 52-year-old man is brought to the emergency department because of increasing shortness of breath for the past 8 hours. Two months ago, he noticed a mass on the right side of his neck and was diagnosed with laryngeal cancer. He has smoked two packs of cigarettes daily for 27 years. He drinks two pints of rum daily. He appears ill. He is oriented to person, place, and time. His temperature is 37°C (98.6°F), pulse is 111/min, respirations are 34/min, and blood pressure is 140/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 89%. Examination shows a 9-cm, tender, firm subglottic mass on the right side of the neck. Cervical lymphadenopathy is present. His breathing is labored and he has audible inspiratory stridor but is able to answer questions. The lungs are clear to auscultation. Arterial blood gas analysis on room air shows: pH 7.36 PCO2 45 mm Hg PO2 74 mm Hg HCO3- 25 mEq/L He has no advanced directive. Which of the following is the most appropriate next step in management?

• A. Comfort care measures
• B. Cricothyroidotomy (Correct Answer)
• C. Tracheostomy
• D. Intramuscular epinephrine
• E. Tracheal stenting

Endocrine Surgery Explanation: ***Correct: Cricothyroidotomy*** - This patient has **impending complete airway obstruction** evidenced by inspiratory stridor, severe tachypnea (34/min), hypoxia (O2 sat 89%), and a large obstructing laryngeal mass - **Cricothyroidotomy** is the emergent surgical airway procedure of choice when there is **imminent or actual complete upper airway obstruction** and endotracheal intubation cannot be safely performed - The subglottic mass makes endotracheal intubation **extremely dangerous** - instrumentation could precipitate complete obstruction and inability to ventilate - Cricothyroidotomy provides **immediate airway access** (can be performed in 30-60 seconds) below the level of obstruction, making it life-saving in this emergency - In the "cannot intubate, cannot ventilate" scenario, cricothyroidotomy is the definitive emergency intervention per ATLS and airway management guidelines *Incorrect: Tracheostomy* - While tracheostomy provides definitive airway management, it is a **controlled, elective procedure** typically performed in the OR that takes 20-30 minutes - This patient requires **immediate airway access** - waiting for OR setup and performing tracheostomy risks complete airway collapse and death - Tracheostomy may be performed later as a planned procedure once the airway is secured with cricothyroidotomy - The presence of stridor indicates **critical airway narrowing** requiring emergency intervention, not elective surgery *Incorrect: Comfort care measures* - The patient is **alert and oriented** without an advanced directive indicating wishes for comfort care only - This is an **acute, reversible condition** with appropriate emergency airway intervention - Presumed consent applies in life-threatening emergencies when the patient cannot formally consent but intervention would be life-saving - Comfort care would be inappropriate without documented patient wishes or irreversible terminal condition *Incorrect: Intramuscular epinephrine* - Epinephrine is indicated for **anaphylaxis** or angioedema causing airway edema from allergic/inflammatory mechanisms - This patient has **mechanical obstruction** from a solid tumor mass, which will not respond to epinephrine - Epinephrine causes vasoconstriction and reduces mucosal edema but cannot reduce tumor mass - Would delay definitive airway management and not address the underlying problem *Incorrect: Tracheal stenting* - Tracheal stenting requires **bronchoscopy** in a controlled setting and is used for palliation of tracheal narrowing - Cannot be performed emergently in an unstable patient with impending airway obstruction - The obstruction is at the **laryngeal/subglottic level**, not typically amenable to emergency stenting - Requires time for procedure setup and sedation, which this patient cannot afford given the critical airway emergency

Endocrine Surgery Flashcard 1 of 5

Question: What surgical procedure involves the en bloc removal of the head/neck of the pancreas, proximal duodenum, and gallbladder?_____

Answer: Whipple procedure

Endocrine Surgery Flashcard 2 of 5

Question: The iliohypogastric nerve is commonly injured due to post abdominal surgery _____

Answer: sutures

Endocrine Surgery Flashcard 3 of 5

Question: Detection of a RET oncogene mutation warrants prophylactic _____

Answer: thyroidectomy

Endocrine Surgery Flashcard 4 of 5

Question: What is the treatment for Cushing disease?_____

Answer: Removal of the ACTH-secreting tumor

Endocrine Surgery Flashcard 5 of 5

Question: What is the treatment for a patient with primary hyperparathyroidism? _____

Answer: Parathyroidectomy