Endocrine Surgery Practice Questions

Q: A professional singer presents with difficulty in raising the pitch of her voice following thyroid surgery. There is no hoarseness, but high-pitched voice production is impaired. Which nerve is most likely injured?

External branch of the superior laryngeal nerve (EBSLN). ***Correct: External branch of the superior laryngeal nerve (EBSLN)*** - The EBSLN innervates the **cricothyroid muscle**, which is responsible for increasing **vocal cord tension** - Injury results in inability to tense the vocal cords, causing **loss of high-pitched voice** production - Crucially, there is **NO hoarseness** because vocal cord adduction (brought together by other muscles) remains intact - Classic presentation: Professional singers or teachers notice difficulty hitting high notes after thyroid surgery *Incorrect: Recurrent laryngeal nerve (RLN)* - RLN innervates all intrinsic laryngeal muscles **except** the cricothyroid - Injury causes **hoarseness** due to impaired vocal cord adduction - This patient has no hoarseness, making RLN injury unlikely *Incorrect: Internal branch of the superior laryngeal nerve (IBSLN)* - IBSLN is purely **sensory** to the supraglottic larynx - Injury causes loss of sensation above the vocal cords, leading to **aspiration risk** - Does not affect voice pitch or motor function *Incorrect: Glossopharyngeal nerve* - Provides motor innervation to stylopharyngeus and sensory to pharynx/posterior tongue - **Not involved in laryngeal function** or voice production - Injury would cause dysphagia and loss of gag reflex, not voice changes

Q: A 50-year-old woman after thyroidectomy comes to you for a 2nd opinion for further treatment of papillary thyroid cancer. What would you recommend for this patient?

Radioactive iodine (RAI) ablation. ***Radioactive iodine (RAI) ablation*** - After total thyroidectomy for papillary thyroid cancer, **radioactive iodine (I-131) ablation** is the standard next step for most patients - **Indications for RAI ablation:** tumor >1 cm, lymph node metastases, extrathyroidal extension, vascular invasion, or unfavorable histology - RAI ablation serves dual purpose: destroys residual thyroid tissue and micro-metastases, and enables follow-up with thyroglobulin levels - A **post-therapy whole body scan** is typically performed 5-7 days after RAI ablation to assess uptake - TSH stimulation (either by thyroid hormone withdrawal or recombinant TSH) is required before RAI therapy *Wait and watch* - Only appropriate for **very low-risk papillary microcarcinomas** (<1 cm, no extrathyroidal extension, no nodal metastases) in carefully selected patients - Not the standard recommendation after thyroidectomy for papillary cancer without risk stratification details *Radiotherapy (External beam)* - **Not first-line** post-operative treatment for differentiated thyroid cancer - Reserved for: RAI-refractory disease, tumors that don't take up iodine, gross residual disease not amenable to surgery, or palliative care - May be considered in elderly patients with aggressive local disease *Chemotherapy* - **No role** in the routine management of differentiated thyroid cancer (papillary or follicular) - Only considered in advanced, progressive, RAI-refractory disease with targeted agents (lenvatinib, sorafenib) - Conventional cytotoxic chemotherapy is ineffective in thyroid cancer

Q: Multiple lytic lesions on skull are seen in which thyroid carcinoma?

Follicular carcinoma. ***Follicular carcinoma*** - Follicular thyroid carcinoma (FTC) classically spreads hematogenously to distant sites, most commonly the **bone (skull, spine, pelvis)** and lungs. - Bone metastases, especially in the skull, are typically **lytic** and may present as solitary or multiple lesions with a characteristic **"cannonball" appearance** on imaging if involving the lungs. ***Papillary carcinoma thyroid*** - Papillary thyroid carcinoma (PTC) predominantly spreads locally via **lymphatics** to regional neck lymph nodes, rarely causing distant metastases early in the disease course. - Distant metastases, when they occur, are usually to the lungs (small micronodules) and are less common as lytic skull lesions compared to FTC. ***Hurthle cell carcinoma*** - Hurthle cell carcinoma (a variant of follicular carcinoma) also has a high propensity for **hematogenous spread** to bone and lung. - While it can cause lytic bone lesions, it is best classified under the broader category of follicular carcinoma for its metastatic pattern, but FTC is the most common association for lytic skull lesions among the choices. ***Thyroid lymphoma*** - Thyroid lymphoma is rare and usually presents as a **rapidly enlarging thyroid mass** in an older patient, often associated with a background of Hashimoto's thyroiditis. - It typically causes diffuse thyroid involvement and local invasion into the neck structures; distant metastases, especially lytic skull lesions, are highly **uncommon**.

Q: Based on the provided X-ray image, identify the type of thyroid malignancy.

Follicular carcinoma. ***Follicular carcinoma*** - This is the **correct answer** based on the X-ray showing bone metastases. - Follicular carcinoma characteristically spreads via **hematogenous (bloodstream) route** to distant sites, particularly **bones and lungs**. - Bone metastases from thyroid cancer are **most commonly** due to follicular carcinoma, presenting as **lytic lesions** on X-ray. - Follicular carcinoma accounts for 10-15% of thyroid cancers but is responsible for the majority of thyroid cancer bone metastases. *Incorrect: Papillary carcinoma* - Although papillary carcinoma is the **most common thyroid malignancy** (80% of cases), it predominantly spreads via **lymphatic route** to regional lymph nodes. - Distant hematogenous metastases to bone are **uncommon** in papillary carcinoma. - When papillary carcinoma does metastasize distantly, lungs are more commonly affected than bones. *Incorrect: Hurthle cell carcinoma* - This is an **aggressive variant of follicular carcinoma** (Hürthle cell or oncocytic variant). - While it can spread hematogenously, it is significantly **rarer** than conventional follicular carcinoma. - It represents only 3-5% of differentiated thyroid cancers. *Incorrect: Thyroid lymphoma* - Primary thyroid lymphoma is a **rare malignancy** typically presenting as a rapidly enlarging neck mass. - Usually occurs in elderly patients with a history of **Hashimoto's thyroiditis**. - Distant bone metastases are **not characteristic** of primary thyroid lymphoma.

Q: What is the triangle shown in the figure known as?

Beahrs triangle. ***Beahrs triangle*** - This image illustrates the **Beahrs triangle**, an anatomical landmark used in thyroid surgery. - It is bounded by the **recurrent laryngeal nerve** (medially), the **common carotid artery** (laterally), and the **inferior thyroid artery** (superiorly). - It is crucial for identifying the **recurrent laryngeal nerve** and ensuring its preservation during thyroidectomy. *Joll's triangle* - This triangle is defined by the **common carotid artery** (medially), the **internal jugular vein** (laterally), and the **superior thyroid artery** (superiorly). - It is used as a landmark to identify the **recurrent laryngeal nerve** during thyroid surgery. - The nerve typically enters this triangle before ascending in the tracheoesophageal groove. *Lore's triangle* - This triangle is located in relation to the **thyroid gland** and is less commonly referenced in standard surgical anatomy. - It has significance in thyroid and laryngeal surgical approaches. *Berry's triangle* - **Berry's ligament** is a fibrous structure that attaches the thyroid gland to the cricoid cartilage and trachea. - **Berry's triangle** is not a commonly recognized anatomical landmark in thyroid surgery like the others listed. - The recurrent laryngeal nerve is at risk near Berry's ligament.

Q: A 35-year-old female presents with a large thyroid swelling. Her chest X-ray is shown below. What is the most likely diagnosis?

Retrosternal goiter. ***Retrosternal goiter*** - A large thyroid swelling coupled with a chest X-ray showing widening of the superior mediastinum and possible **tracheal deviation or compression** (indicated by the arrows), strongly suggests a retrosternal goiter. - The thyroid gland, when enlarged, can extend into the thorax behind the sternum, known as a **retrosternal (or plunging) goiter**, which is a common cause of a superior mediastinal mass. *Sarcoidosis* - Sarcoidosis primarily causes **hilar and mediastinal lymphadenopathy** and pulmonary infiltrates, not typically a large, unilateral mediastinal mass pushing the trachea. - While it can cause superior mediastinal widening due to lymph nodes, it usually doesn't present as a distinct mass readily associated with a thyroid swelling. *Thymoma* - Thymomas are typically found in the **anterior mediastinum** and can present as a mediastinal mass, but are not usually associated with a palpable thyroid swelling. - The imaging features of a thymoma would generally be a well-defined mass in the anterior mediastinum, rather than a mass clearly originating from the neck and descending. *Superior vena cava syndrome* - Superior vena cava syndrome (SVCS) is a clinical syndrome caused by obstruction of the superior vena cava, leading to symptoms like **facial swelling, distended neck veins, and dyspnea**. - While a mediastinal mass can cause SVCS, SVCS itself is a **clinical manifestation** (a syndrome), not a diagnosis for the mass itself. The question asks for the most likely diagnosis of the mass.

Q: Which amongst the following is commonly seen in this patient with neck swelling with bosselated appearance?

Dysphagia. ***Dysphagia*** - A large thyroid swelling, particularly one with a "bosselated" (nodular/irregular) appearance, can cause **compression of the esophagus**, leading to difficulty swallowing. - The image clearly shows a significant mass in the neck, consistent with a goiter or thyroid tumor, which can mechanically obstruct the passage of food. *Anaplastic carcinoma* - While anaplastic carcinoma is a rapidly growing and aggressive thyroid cancer that can cause a large, irregular neck mass, it is not a *symptom* that the patient experiences. It is a specific diagnosis. - Patients with anaplastic carcinoma often present with **rapidly enlarging neck mass**, **hoarseness**, and **dyspnea**, in addition to dysphagia. *SVC syndrome* - **Superior Vena Cava (SVC) syndrome** is characterized by facial and arm swelling, prominent collateral veins on the chest, and sometimes dyspnea, resulting from compression or obstruction of the SVC. - This condition is typically caused by lung cancer, lymphoma, or other mediastinal masses, not directly by a thyroid swelling causing a bosselated neck appearance. *Follicular carcinoma* - **Follicular carcinoma** is a type of thyroid cancer that usually presents as a solitary, **firm nodule** and is characterized by its tendency for **hematogenous spread**. - While it can cause neck swelling, the "bosselated appearance" and the prominent mass shown are more directly linked to the *symptom* of dysphagia due to mass effect, rather than follicular carcinoma being the *most common symptom* itself.

Q: Which of the following statements regarding Thyroglossal duct are correct ? 1. It is situated in midline of neck. 2. It moves upwards on swallowing but not on tongue protrusion. 3. It is treated with Sistrunk operation. 4. It may be the only functioning thyroid tissue in the body. Select the correct answer using the code given below :

1, 3 and 4. ***1, 3 and 4*** - The **thyroglossal duct** is embryological remnant located in the **midline of the neck** and often presents as a cyst. - The **Sistrunk operation** is the definitive surgical treatment for **thyroglossal duct cysts**, involving removal of the cyst, the midline portion of the hyoid bone, and the tract to the foramen cecum. - In some cases, a **thyroglossal duct cyst** may harbor the patient's only functional **thyroid tissue**, making preoperative imaging crucial to avoid inadvertently causing hypothyroidism. *1, 2 and 3* - This option incorrectly states that the thyroglossal duct moves upwards only on swallowing and not on **tongue protrusion**. - In fact, its connection to the foramen cecum at the base of the tongue means it **elevates with tongue protrusion** as well as swallowing. *2, 3 and 4* - This option incorrectly states that the **thyroglossal duct** moves upwards only on swallowing and not on **tongue protrusion**. - The **midline location** (statement 1) is a key characteristic of thyroglossal duct remnants and is correctly included in the comprehensive correct option. *1, 2 and 4* - This option incorrectly claims that the thyroglossal duct moves upwards only on swallowing and not on **tongue protrusion**. - It also omits the **Sistrunk operation** (statement 3), which is the standard surgical treatment for **thyroglossal duct cysts**.

Q: A 60-year-old lady presents with a recent onset increase in a long standing swelling on the front of the neck. The swelling, which was small, had been present since last 30 years, but has now increased to more than twice the size in the last 2 months. On examination, the swelling is firm to hard in consistency and moves with deglutition. What is the most likely cause of this clinical presentation?

Malignant transformation. ***Malignant transformation*** - A long-standing **benign thyroid swelling** (like a nodular goiter or adenoma) in an older patient that suddenly and rapidly increases in size, becomes firm/hard, and is associated with new symptoms suggests **malignant transformation**. - Additionally, factors like age over 60, female sex and change in consistency are concerning for **thyroid carcinoma**. *Myxomatous transformation* - This typically refers to the accumulation of **mucinous material** and is not a common or principal cause of rapid, significant enlargement and hardening in a long-standing thyroid swelling. - It does not explain the **rapid increase in size** and **firm consistency** described. *Haemorrhage* - While hemorrhage into a thyroid nodule can cause a **sudden increase in size** and pain, it usually presents as an acutely painful, tender swelling, and the consistency might be tense but not typically described as "firm to hard." - The rapid change in size over **two months** is more suggestive of cellular proliferation rather than a resolving bleed. *Cystic degeneration* - Cystic degeneration can explain some fluctuation in size over time, but a **rapid increase to more than twice the size** within two months, especially accompanied by a **firm to hard consistency**, is not characteristic of simple cystic change. - Cysts are typically softer or fluctuant on palpation, not firm and hard.

Q: A midline neck swelling just below the hyoid bone and managed by Sistrunk's operation leads to postoperative need for thyroxine replacement. The most likely diagnosis is

thyroglossal cyst with only functioning thyroid tissue. ***thyroglossal cyst with only functioning thyroid tissue*** - A midline neck swelling below the hyoid bone is characteristic of a **thyroglossal cyst**. The need for **thyroxine replacement** post-Sistrunk's operation indicates that this cyst contained the patient's **only functioning thyroid tissue**. - In such rare cases, the body's entire thyroid gland develops abnormally within the thyroglossal duct, explaining the subsequent **hypothyroidism** after its removal. *solitary thyroid nodule* - A **solitary thyroid nodule** is typically located within the thyroid gland itself, which is lower in the neck than "just below the hyoid bone." - Simple removal of a solitary benign thyroid nodule would not, on its own, necessitate **thyroxine replacement** unless a total thyroidectomy was performed for other reasons, or the patient had underlying thyroid dysfunction. *thyroglossal cyst* - While a **thyroglossal cyst** fits the description of a midline neck swelling below the hyoid, simply diagnosing it as a cyst doesn't explain the need for **thyroxine replacement**. - Most thyroglossal cysts are benign and contain no functional thyroid tissue, so their removal via a Sistrunk's operation does not typically lead to **hypothyroidism**. *lateral aberrant thyroid* - **Lateral aberrant thyroid tissue** is typically found in the lateral neck, often associated with a branchial cleft anomaly, not in the midline below the hyoid bone. - While it can contain functional thyroid tissue, its location and the specific context of a Sistrunk's operation pointing to a midline anomaly make this diagnosis less likely.

Question 1

A professional singer presents with difficulty in raising the pitch of her voice following thyroid surgery. There is no hoarseness, but high-pitched voice production is impaired. Which nerve is most likely injured?

Accepted Answer

External branch of the superior laryngeal nerve (EBSLN)

Answer

Glossopharyngeal nerve

Answer

Internal branch of the superior laryngeal nerve (IBSLN)

Answer

Recurrent laryngeal nerve (RLN)

Question 2

A 50-year-old woman after thyroidectomy comes to you for a 2nd opinion for further treatment of papillary thyroid cancer. What would you recommend for this patient?

Accepted Answer

Radioactive iodine (RAI) ablation

Answer

Wait and watch.

Answer

Radiotherapy

Answer

Chemotherapy

Question 3

Multiple lytic lesions on skull are seen in which thyroid carcinoma?

Accepted Answer

Follicular carcinoma

Answer

Thyroid lymphoma

Answer

Papillary carcinoma thyroid

Answer

Hurthle cell carcinoma

Question 4

Based on the provided X-ray image, identify the type of thyroid malignancy.

Accepted Answer

Follicular carcinoma

Answer

Papillary carcinoma

Answer

Hurthle cell carcinoma

Answer

Thyroid lymphoma

Question 5

What is the triangle shown in the figure known as?

Accepted Answer

Beahrs triangle

Answer

Joll's triangle

Answer

Lore's triangle

Answer

Berry's triangle

Question 6

A 35-year-old female presents with a large thyroid swelling. Her chest X-ray is shown below. What is the most likely diagnosis?

Accepted Answer

Retrosternal goiter

Answer

Sarcoidosis

Answer

Thymoma

Answer

Superior vena cava syndrome

Question 7

Which amongst the following is commonly seen in this patient with neck swelling with bosselated appearance?

Accepted Answer

Dysphagia

Answer

Anaplastic carcinoma

Answer

SVC syndrome

Answer

Follicular carcinoma

Question 8

Which of the following statements regarding Thyroglossal duct are correct ?

1. It is situated in midline of neck.
2. It moves upwards on swallowing but not on tongue protrusion.
3. It is treated with Sistrunk operation.
4. It may be the only functioning thyroid tissue in the body.

Select the correct answer using the code given below :

Accepted Answer

1, 3 and 4

Answer

1, 2 and 3

Answer

2, 3 and 4

Answer

1, 2 and 4

Question 9

A 60-year-old lady presents with a recent onset increase in a long standing swelling on the front of the neck. The swelling, which was small, had been present since last 30 years, but has now increased to more than twice the size in the last 2 months. On examination, the swelling is firm to hard in consistency and moves with deglutition. What is the most likely cause of this clinical presentation?

Accepted Answer

Malignant transformation

Answer

Myxomatous transformation

Answer

Haemorrhage

Answer

Cystic degeneration

Question 10

A midline neck swelling just below the hyoid bone and managed by Sistrunk's operation leads to postoperative need for thyroxine replacement. The most likely diagnosis is

Accepted Answer

thyroglossal cyst with only functioning thyroid tissue

Answer

solitary thyroid nodule

Answer

thyroglossal cyst

Answer

lateral aberrant thyroid

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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