Thyroid cancer management US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Thyroid cancer management. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Thyroid cancer management US Medical PG Question 1: A 36-year-old woman comes to the physician for a follow-up visit after she had a PET scan that showed a nodule on the thyroid gland. She has no difficulty or pain while swallowing. She was treated for non-Hodgkin lymphoma at the age of 28 years, which included external beam radiation to the head and neck and 4 cycles of chemotherapy. She appears healthy. Vital signs are within normal limits. Physical examination shows no abnormalities. Serum studies show:
Glucose 82 mg/dL
Creatinine 0.7 mg/dL
Thyroid-stimulating hormone 3 μU/mL
Ultrasound of the neck shows a 1.2-cm (0.5-in) nodule on the left lobe of the thyroid with irregular margins and microcalcifications. A fine-needle aspiration biopsy shows Psammoma bodies and cells with clear, ground-glass, empty nuclei. Which of the following is the most appropriate next step in management?
- A. Thyroid scintigraphy
- B. Observation and follow-up in 3 months
- C. Radioiodine therapy
- D. Total thyroidectomy (Correct Answer)
Thyroid cancer management Explanation: ***Total thyroidectomy***
- The fine-needle aspiration biopsy findings of **Psammoma bodies** and **clear, ground-glass, empty nuclei** are classic for **papillary thyroid carcinoma**, which is the most common type of thyroid cancer.
- Given the patient's history of **neck radiation** for lymphoma (a risk factor for thyroid cancer), the concerning ultrasound features (irregular margins, microcalcifications), and the confirmed diagnosis of papillary thyroid carcinoma, **total thyroidectomy** is the definitive treatment.
*Thyroid scintigraphy*
- **Thyroid scintigraphy** is primarily used to assess the functional status of thyroid nodules (hot vs. cold) and is helpful if the TSH is suppressed or if the FNA is indeterminate.
- In this case, the **fine-needle aspiration (FNA) biopsy** has already provided a definitive diagnosis of papillary thyroid cancer, making scintigraphy unnecessary for initial management.
*Observation and follow-up in 3 months*
- **Observation** is not appropriate given the definitive diagnosis of **papillary thyroid carcinoma** confirmed by biopsy and the patient's history of neck radiation.
- Papillary thyroid cancer, although often slow-growing, requires active management, especially with adverse features on ultrasound and a clear diagnosis.
*Radioiodine therapy*
- **Radioiodine therapy** is typically used as **adjuvant treatment** *after* thyroidectomy to ablate residual thyroid tissue or treat metastatic disease, particularly in higher-risk cases.
- It is not the primary treatment for localized papillary thyroid carcinoma.
Thyroid cancer management US Medical PG Question 2: A 25-year-old man presents with a mass on his neck. He says that he first noticed the mass a few weeks ago while taking a shower. Since then, the mass has not increased in size. He denies any pain or difficulty in swallowing. Past medical history is unremarkable. Family history is significant for his father who had his thyroid removed when he was around his age but doesn’t know why. Review of systems is significant for occasional episodes of anxiety that include a pounding headache, racing heart, and sweating. His vital signs include: pulse 88/min, blood pressure 133/87 mm Hg, temperature 37.2°C (99.0°F), and respiratory rate 14/min. He is 183 cm (6 ft 2 in) tall with long extremities. On physical examination, the patient appears cachectic. There is a palpable 4 cm x 4 cm nodule present on the left lobe of the thyroid. Which of the following is the most likely thyroid pathology in this patient?
- A. Follicular adenoma
- B. Medullary carcinoma (Correct Answer)
- C. Giant cell thyroiditis
- D. Papillary carcinoma
- E. Anaplastic carcinoma
Thyroid cancer management Explanation: ***Medullary carcinoma***
- This patient's presentation with a **neck mass**, family history of thyroid removal at a young age, and episodic symptoms of **pounding headache, racing heart, and sweating** (suggestive of **pheochromocytoma**) strongly points to medullary thyroid carcinoma (MTC) as part of **Multiple Endocrine Neoplasia type 2B (MEN 2B)**.
- The **tall stature, long extremities, and cachectic appearance** (Marfanoid habitus) are characteristic features of **MEN 2B syndrome**, which consists of MTC, pheochromocytoma, Marfanoid habitus, and mucosal neuromas.
- MTC arises from **parafollicular C cells** and secretes **calcitonin**; it is associated with **RET proto-oncogene mutations** in hereditary cases.
*Follicular adenoma*
- While follicular adenomas can present as a **solitary thyroid nodule**, they are **benign** and do not present with the systemic symptoms (anxiety-like episodes, palpitations, headaches) or family history suggestive of a hereditary cancer syndrome.
- There is no association with **pheochromocytoma** or **Marfanoid habitus**.
*Giant cell thyroiditis*
- **Giant cell thyroiditis (subacute thyroiditis/De Quervain thyroiditis)** is characterized by a **painful, tender thyroid** nodule, often preceded by a viral upper respiratory infection.
- The patient's nodule is described as **non-painful**, and his symptoms do not align with the typical course of thyroiditis (fever, elevated ESR, transient hyperthyroidism).
*Papillary carcinoma*
- **Papillary thyroid carcinoma** is the most common type of thyroid cancer and typically presents as a **painless thyroid nodule**.
- However, it is **not associated** with a strong family history of early-onset thyroid disease, episodic symptoms suggesting **pheochromocytoma**, or **Marfanoid habitus**, unlike medullary carcinoma in MEN 2B.
*Anaplastic carcinoma*
- **Anaplastic thyroid carcinoma** is a highly aggressive cancer, usually presenting in **older individuals (>60 years old)** with a **rapidly enlarging, painful neck mass** and symptoms of local **compression** (dyspnea, dysphagia, hoarseness).
- The patient's **young age** (25 years) and the **non-aggressive nature** of the mass (stable size over weeks) make anaplastic carcinoma highly unlikely.
Thyroid cancer management US Medical PG Question 3: A 74-year-old retired female teacher is referred to the endocrinology clinic. She is very concerned about a large mass in her neck that has progressively enlarged over the past 2 weeks. She also reports a 15 pound weight loss over the last 3 months. She now has hoarseness and difficulty swallowing her food, giving her a sensation that food gets stuck in her windpipe when she swallows. There is no pain associated with swallowing. Her speech is monotonous. No other gait or language articulation problems are noted. Testing for cranial nerve lesions is unremarkable. On palpation, a large, fixed and non-tender mass in the thyroid is noted. Cervical lymph nodes are palpable bilaterally. The patient is urgently scheduled for an ultrasound-guided fine needle aspiration to guide management. Which of the following is the most likely gene mutation to be found in this mass?
- A. Activating mutation of the Ras protooncogene
- B. Inactivating mutation of the p53 tumor suppressor gene (Correct Answer)
- C. RET/PTC rearrangement
- D. BRAF mutation
- E. RET gene mutation
Thyroid cancer management Explanation: ***Inactivating mutation of the p53 tumor suppressor gene***
- The patient's presentation with a **rapidly enlarging, fixed, non-tender thyroid mass**, *hoarseness*, *dysphagia*, *weight loss*, and *palpable cervical lymph nodes* is highly suggestive of **anaplastic thyroid carcinoma (ATC)**, an aggressive malignancy.
- Inactivating mutations of the **p53 tumor suppressor gene** are frequently associated with the development and progression of ATC, contributing to its uncontrolled growth and poor prognosis.
*Activating mutation of the Ras protooncogene*
- **Ras mutations** are more commonly found in *follicular thyroid carcinoma* and *follicular variants of papillary thyroid carcinoma*.
- While they can indicate malignancy, they are not typically the primary genetic driver for the highly aggressive features seen in anaplastic carcinoma.
*RET/PTC rearrangement*
- **RET/PTC rearrangements** are characteristic genetic alterations found in **papillary thyroid carcinoma (PTC)**.
- PTC typically presents with a *slower growth rate* and *less aggressive features* compared to the rapid progression described in the patient.
*BRAF mutation*
- The **BRAF V600E mutation** is the most common genetic alteration in **papillary thyroid carcinoma (PTC)**, especially the conventional and tall-cell variants.
- While it indicates a more aggressive subset of PTC, it is generally not the primary mutation associated with the extremely aggressive and rapidly progressing features of anaplastic thyroid carcinoma.
*RET gene mutation*
- **Germline RET mutations** are primarily associated with **medullary thyroid carcinoma (MTC)**, often occurring as part of Multiple Endocrine Neoplasia type 2 (MEN2).
- The clinical presentation with a *rapidly growing, fixed mass* and *compressive symptoms* is less typical for MTC, which can also be aggressive but usually presents differently.
Thyroid cancer management US Medical PG Question 4: A 47-year-old woman presents to the clinic complaining of difficulty swallowing that started 1 month ago. The patient also reports a weight loss of 10 lbs during this time, without a change in her appetite. She denies fatigue, cough, hoarseness, pain, or hemoptysis. The patient has a history of childhood lymphoma, which was treated with radiation. She takes no medications. She has smoked 1 pack of cigarettes per day since she was 25 years old. Her physical exam is notable for a palpable nodule on the right side of the thyroid. An ultrasound is performed, which confirms a 1.2 cm hyperechoic nodule in the right lobe. Thyroid function labs are drawn and shown below:
Serum TSH: 0.2 mU/L
Serum thyroxine (T4): 187 nmol/L
Serum triiodothyronine (T3): 3.3 nmol/L
Which of the following is the next best step in management?
- A. Radioactive iodine
- B. Partial thyroidectomy
- C. Fine needle aspiration (Correct Answer)
- D. Levothyroxine
- E. Thyroid scintigraphy
Thyroid cancer management Explanation: ***Fine needle aspiration***
- This patient has several risk factors for **thyroid malignancy**, including a history of **radiation exposure** to the neck (for childhood lymphoma) and a palpable thyroid nodule associated with **dysphagia** and unexplained **weight loss**. Fine needle aspiration (FNA) is the best next step to evaluate for malignancy.
- The patient also presents with **hyperthyroidism** (low TSH, elevated T4), but the primary concern given the clinical picture is to rule out thyroid cancer.
- Per American Thyroid Association guidelines, FNA is indicated for any nodule in a patient with a history of head/neck radiation exposure.
*Radioactive iodine*
- Radioactive iodine ablation is used to treat **hyperthyroidism**, especially in cases of **Graves' disease** or toxic nodular goiter. While the patient has hyperthyroidism, the presence of a suspicious nodule warrants investigation for malignancy first.
- Administering radioactive iodine without first ruling out malignancy in a suspicious nodule could delay definitive treatment for cancer or complicate its management.
*Partial thyroidectomy*
- **Partial thyroidectomy** would be considered if the FNA results indicate malignancy or a highly suspicious follicular neoplasm.
- Performing surgery without a prior FNA would be premature, as many thyroid nodules are benign and do not require surgical intervention unless causing compressive symptoms or confirmed malignancy.
*Levothyroxine*
- **Levothyroxine** is used to treat **hypothyroidism** or to suppress TSH in cases of benign thyroid nodules or after thyroid cancer surgery.
- This patient is **hyperthyroid**, making exogenous levothyroxine inappropriate.
*Thyroid scintigraphy*
- **Thyroid scintigraphy** (radioactive iodine uptake scan) is useful in characterizing thyroid nodules as "hot" (functioning) or "cold" (non-functioning) in the context of hyperthyroidism.
- "Hot" nodules are rarely malignant, while "cold" nodules have a higher (though still relatively low) risk of malignancy. However, given the patient's strong risk factors for thyroid cancer and compressive symptoms, an FNA is more direct and informative for assessing malignancy than scintigraphy at this stage.
Thyroid cancer management US Medical PG Question 5: A 38-year-old woman undergoes hemithyroidectomy for treatment of localized, well-differentiated papillary thyroid carcinoma. The lesion is removed with clear margins. However, during the surgery, a structure lying directly adjacent to the superior thyroid artery at the upper pole of the thyroid lobe is damaged. This patient is most likely to experience which of the following symptoms?
- A. Shortness of breath
- B. Weakness of shoulder shrug
- C. Voice pitch limitation (Correct Answer)
- D. Difficulty swallowing
- E. Ineffective cough
Thyroid cancer management Explanation: ***Voice pitch limitation***
- Damage to the structure directly adjacent to the **superior thyroid artery** at the upper pole of the thyroid likely involves the **external branch of the superior laryngeal nerve (EBSLN)**.
- This nerve innervates the **cricothyroid muscle**, which is responsible for **tensing the vocal cords** and controlling **voice pitch**.
- Injury results in inability to change pitch, voice fatigue during prolonged speaking, and reduced vocal range.
*Shortness of breath*
- While damage to other nerves like the **recurrent laryngeal nerve** could cause vocal cord paralysis and potentially lead to airway compromise, this is less directly associated with the superior thyroid artery.
- Shortness of breath is not the specific consequence of EBSLN injury near the superior thyroid artery.
*Weakness of shoulder shrug*
- Weakness of shoulder shrug is associated with damage to the **spinal accessory nerve (cranial nerve XI)**, which innervates the **trapezius muscle**.
- This nerve is anatomically distinct from structures near the superior thyroid artery at the upper pole of the thyroid.
*Difficulty swallowing*
- Difficulty swallowing (dysphagia) can result from damage to the **vagus nerve (cranial nerve X)** or its pharyngeal branches, but it is not the direct consequence of injury near the superior thyroid artery.
- Damage to the EBSLN primarily affects voice pitch and quality, not swallowing.
*Ineffective cough*
- An ineffective cough results from paralysis of the vocal cords (preventing glottic closure) or weakness of respiratory muscles, typically from **recurrent laryngeal nerve** damage or phrenic nerve injury.
- EBSLN damage primarily affects voice pitch and does not significantly impair cough effectiveness.
Thyroid cancer management US Medical PG Question 6: A 30-year-old woman is brought to the urgent care clinic by her husband. She complains of numbness around her lips and a tingling sensation in her hands and feet. She underwent near-total thyroidectomy for an enlarged thyroid gland a month ago. Vital signs include: blood pressure is 130/70 mm Hg, pulse is 72/min, respiratory rate is 16/min, and temperature is 37.0°C (98.6°F). A surgical incision scar is present in the anterior aspect of the neck. The attending physician inflates the blood pressure cuff above 150 mm Hg and observes the patient a couple of minutes while measuring her blood pressure. The patient develops sudden stiffness and tingling in her hand. Blood test results are as follows:
Hemoglobin (Hb%) 10.2 g/dL
White blood cell count 7000/mm3
Platelet count 160,000/mm3
Calcium, serum (Ca2+) 6.0 mg/dL
Albumin 4 g/dL
Alanine aminotransferase (ALT), serum 15 U/L
Aspartate aminotransferase (AST), serum 8 U/L
Serum creatinine 0.5 mg/dL
Urea 27 mg/dL
Sodium 137 mEq/L
Potassium 4.5 mEq/L
Magnesium 2.5 mEq/L
Urinalysis shows no white or red blood cells and leukocyte esterase is negative. Which of the following is the next best step in the management of this patient?
- A. 24-hour urinary calcium
- B. Serum vitamin D level
- C. CT scan abdomen with pancreatic protocol
- D. Thyroid function tests
- E. Serum parathyroid hormone (PTH) level (Correct Answer)
Thyroid cancer management Explanation: ***Serum parathyroid hormone (PTH) level***
- The patient presents with **symptoms of hypocalcemia** (perioral numbness, tingling in hands and feet, positive Trousseau's sign, and serum calcium of 6.0 mg/dL) following a **near-total thyroidectomy**.
- Measuring **PTH levels** is crucial to determine if the hypocalcemia is due to **parathyroid gland damage** (low PTH) or another cause (high PTH).
*24-hour urinary calcium*
- This test is primarily used in the workup of **hypercalcemia** or **kidney stone disease** to assess calcium excretion.
- It is **not the initial diagnostic step** for symptomatic hypocalcemia post-thyroidectomy.
*Serum vitamin D level*
- While **vitamin D deficiency** can contribute to hypocalcemia, the acute onset of symptoms following thyroid surgery strongly points to parathyroid involvement.
- Addressing the **immediate calcium deficit** and evaluating PTH are higher priorities than measuring vitamin D levels at this stage.
*CT scan abdomen with pancreatic protocol*
- A CT scan of the abdomen with pancreatic protocol is used to evaluate **pancreatic pathology**, such as pancreatitis or tumors.
- This investigation is **irrelevant** to the patient's symptoms and recent thyroid surgery.
*Thyroid function tests*
- While important for managing patients post-thyroidectomy, routine thyroid function tests (TSH, T3, T4) are primarily to assess for **hypothyroidism** or **hyperthyroidism**.
- They do **not directly explain acute hypocalcemic symptoms** or guide immediate management of low calcium.
Thyroid cancer management US Medical PG Question 7: A 55-year-old woman comes to the physician because of a 4-month history of a painless lump on her neck. Examination shows a hard nodule on the left side of her neck. A fine-needle aspiration biopsy shows well-differentiated cuboidal cells arranged spherically around colloid. She undergoes thyroidectomy. Histopathological examination of the surgical specimen shows invasion of the thyroid capsule and blood vessels. Which of the following cellular events is most likely involved in the pathogenesis of this patient's condition?
- A. TSH receptor gene mutation
- B. Activation mutation in the BRAF gene
- C. Mutation in the RET proto-oncogene
- D. p53 tumor suppressor gene inactivation
- E. PAX8-PPAR gamma gene rearrangement (Correct Answer)
Thyroid cancer management Explanation: ***PAX8-PPAR gamma gene rearrangement***
- The description of a **painless neck lump**, **well-differentiated cuboidal cells arranged spherically around colloid**, and **invasion of the thyroid capsule and blood vessels** is highly classic for **follicular thyroid carcinoma**.
- **PAX8-PPAR gamma rearrangement** is a characteristic genetic alteration found in a significant subset of **follicular thyroid carcinomas** and sometimes in follicular adenomas, playing a crucial role in tumorigenesis.
*TSH receptor gene mutation*
- This mutation is associated with **toxic thyroid adenomas** (Plummer's disease) and **diffuse toxic goiter** (Graves' disease), leading to hyperthyroidism.
- While it can cause nodular growth, it typically results in a **hyperfunctioning nodule** and is not primarily linked to the invasive features of follicular carcinoma described.
*Activation mutation in the BRAF gene*
- **BRAF V600E mutation** is the most common genetic alteration found in **papillary thyroid carcinoma**, which typically presents with **papillary architecture**, nuclear features like **Orphan Annie eye nuclei**, and **psammoma bodies**.
- The histological description of "well-differentiated cuboidal cells arranged spherically around colloid" does not fit papillary carcinoma.
*Mutation in the RET proto-oncogene*
- **RET proto-oncogene mutations** are characteristic of **medullary thyroid carcinoma**, a neuroendocrine tumor arising from parafollicular C cells.
- Medullary thyroid carcinoma has distinct histological features (e.g., amyloid deposition) and clinical presentations (e.g., calcitonin secretion) that are not described in this case.
*p53 tumor suppressor gene inactivation*
- **p53 inactivation** is primarily associated with **anaplastic thyroid carcinoma** and **poorly differentiated thyroid carcinoma**.
- These are highly aggressive tumors that would present with rapid growth, significant invasion, and poorly differentiated or anaplastic histology, which contradicts the "well-differentiated" description in the patient's biopsy.
Thyroid cancer management US Medical PG Question 8: 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
Thyroid cancer management 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.
Thyroid cancer management US Medical PG Question 9: Three hours after undergoing a total right hip replacement, a 71-year-old woman has tingling around the lips and numbness in her fingertips. Her surgery was complicated by unintentional laceration of the right femoral artery that resulted in profuse bleeding. She appears uncomfortable. Examination shows an adducted thumb, extended fingers, and flexed metacarpophalangeal joints and wrists. Tapping on the cheeks leads to contraction of the facial muscles. Which of the following is the most likely cause of this patient's symptoms?
- A. Acute kidney injury
- B. Parathyroid ischemia
- C. Intravascular hemolysis
- D. Calcium chelation (Correct Answer)
- E. Metabolic acidosis
Thyroid cancer management Explanation: ***Calcium chelation***
- The patient exhibits symptoms of **hypocalcemia**, including perioral tingling, fingertip numbness, **Trousseau sign** (adducted thumb, extended fingers, flexed metacarpophalangeal joints and wrists), and **Chvostek's sign** (facial muscle contraction upon tapping the cheek).
- Her significant blood loss and subsequent transfusion likely involved large volumes of **citrated blood products** (e.g., packed red blood cells), where citrate acts as an **anticoagulant** by chelating calcium, leading to transient hypocalcemia.
*Acute kidney injury*
- While acute kidney injury can cause electrolyte imbalances, it typically leads to **hyperphosphatemia**, not necessarily acute symptomatic hypocalcemia presenting within hours of surgery in this manner.
- The patient's immediate post-operative presentation points away from kidney injury being the primary cause of these acute neurological symptoms.
*Parathyroid ischemia*
- **Parathyroid ischemia** could cause hypocalcemia due to reduced parathyroid hormone production, but it is typically associated with **neck surgeries** (e.g., thyroidectomy) and not directly with hip replacement or arterial laceration.
- The onset of symptoms within hours of surgery is too rapid for parathyroid ischemia to fully manifest, as the half-life of PTH is short, but the subsequent drop in calcium would take longer to become clinically significant.
*Intravascular hemolysis*
- **Intravascular hemolysis** can occur due to transfusion reactions or other causes, leading to symptoms like fever, chills, and hemoglobinuria.
- It does not directly cause the specific neurological signs of hypocalcemia described (Trousseau's and Chvostek's signs).
*Metabolic acidosis*
- **Metabolic acidosis** can alter calcium binding to albumin, leading to an **increase in ionized calcium** (the physiologically active form), rather than a decrease.
- While acidosis can occur after massive blood loss and shock, it would not explain the classic signs of hypocalcemia.
Thyroid cancer management 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
Thyroid cancer management 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
More Thyroid cancer management US Medical PG questions available in the OnCourse app. Practice MCQs, flashcards, and get detailed explanations.
