Endocrine Surgery Practice Questions

Q: What is the best surgical approach for accessing a retrosternal goitre?

Cervical approach. ### Explanation **Why the Cervical Approach is Correct:** The majority of retrosternal goitres (approximately 90–95%) are **primary cervical goitres** that have descended into the mediastinum due to gravity, negative intrathoracic pressure, and the lack of anatomical barriers at the thoracic inlet. Because these goitres derive their blood supply from the **inferior thyroid arteries** (branches of the thyrocervical trunk in the neck), they can almost always be safely delivered and resected through a standard **transverse cervical (Kocher) incision**. Digital dissection along the plane of the thyroid capsule allows the surgeon to gently "deliver" the mass into the neck. **Analysis of Incorrect Options:** * **Sternal Approach (Sternotomy):** This is reserved for only 2–5% of cases. Indications for sternotomy include "true" ectopic intrathoracic goitres (blood supply from internal mammary or aorta), recurrent goitres, malignancy with mediastinal lymphadenopathy, or an "iceberg" goitre where the diameter exceeds the thoracic inlet. * **VATS (Video-Assisted Thoracoscopic Surgery):** While used for some mediastinal masses, it is not the primary approach for retrosternal goitres because the vascular control (inferior thyroid artery) is superiorly located in the neck. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** A goitre is considered retrosternal if more than 50% of its volume is below the level of the thoracic inlet. * **Pemberton’s Sign:** Facial congestion and inspiratory stridor upon raising both arms above the head; indicates superior vena cava syndrome or thoracic inlet obstruction. * **Most common complication:** Recurrent laryngeal nerve injury and hypoparathyroidism are slightly more common in retrosternal cases compared to simple thyroidectomies. * **Key Rule:** Always secure the superior pole and the middle thyroid vein first to mobilize the gland before attempting to deliver the retrosternal component.

Q: A 3 cm adrenal mass is found incidentally on a CT scan. Which of the following investigations is NOT indicated?

Adrenalectomy. **Explanation:** The clinical scenario describes an **Adrenal Incidentaloma**, defined as an adrenal mass ≥1 cm discovered on imaging performed for reasons other than suspected adrenal disease. The primary goal in managing an incidentaloma is to determine if the mass is **hormonally active** or **malignant**. **Why Adrenalectomy is the correct answer:** Adrenalectomy is a **treatment**, not an investigation. It is only indicated if the mass is functional (hormone-secreting), shows suspicious radiological features (e.g., size >4 cm, high Hounsfield units), or increases in size during follow-up. A 3 cm non-functional mass with benign features is typically managed with observation, making immediate surgery inappropriate as an initial diagnostic step. **Analysis of Incorrect Options (Necessary Investigations):** * **Dexamethasone Suppression Test (DST):** Essential to screen for **Subclinical Cushing’s Syndrome** (autonomous cortisol secretion), which is the most common hormonal abnormality in incidentalomas. * **Measurement of Plasma Catecholamines/Metanephrines:** Mandatory to rule out **Pheochromocytoma**, even in asymptomatic patients, as an undiagnosed pheochromocytoma can lead to a lethal hypertensive crisis during biopsy or surgery. * **Midnight Plasma Cortisol:** Used to assess the loss of circadian rhythm, another sensitive marker for autonomous cortisol production. **High-Yield Clinical Pearls for NEET-PG:** 1. **Size Cut-off:** Masses **>4 cm** have a higher risk of malignancy and are generally recommended for resection. 2. **Biopsy Rule:** Never perform a Fine Needle Aspiration (FNA) of an adrenal mass until **Pheochromocytoma is ruled out** biochemically. 3. **Hounsfield Units (HU):** On non-contrast CT, a density of **<10 HU** suggests a lipid-rich benign adenoma. 4. **Conn’s Screening:** If the patient is hypertensive or hypokalemic, the **Aldosterone-to-Renin Ratio (ARR)** must also be checked.

Q: A patient underwent thyroidectomy for hyperthyroidism. Two days later, the patient presented with features of thyroid storm. What is the most likely cause?

Inadequate preoperative preparation. ### Explanation **1. Why "Inadequate Preoperative Preparation" is correct:** The primary goal of preoperative management in hyperthyroidism (especially Graves' disease) is to achieve a **euthyroid state** before surgery. If a patient is not properly prepared with antithyroid drugs (like Carbimazole or Methimazole) and Beta-blockers, the thyroid gland remains hyperactive. Surgical manipulation of an overactive gland triggers a massive release of stored thyroid hormones (T3 and T4) into the circulation. This sudden surge precipitates a **Thyroid Storm**, a life-threatening hypermetabolic state characterized by hyperpyrexia, tachycardia, and cardiac failure. **2. Why other options are incorrect:** * **Poor antibiotic coverage:** While this increases the risk of surgical site infection or sepsis, it does not directly trigger the hormonal surge characteristic of a thyroid storm. * **Rough handling during surgery:** While excessive manipulation can exacerbate hormone release, it rarely causes a storm if the patient was adequately prepared and euthyroid. Preparation is the definitive preventive factor. * **Removal of parathyroid:** This leads to **hypocalcemia** (tetany, Chvostek’s/Trousseau’s signs), not thyroid storm. **3. Clinical Pearls for NEET-PG:** * **Lugol’s Iodine:** Often given 10 days preoperatively to decrease the **vascularity** and friability of the gland (Plummer’s effect). * **Drug of choice for Thyroid Storm:** **Propylthiouracil (PTU)** is preferred over Methimazole because it also inhibits the peripheral conversion of T4 to T3. * **Beta-blockers (Propranolol):** Essential to control adrenergic symptoms and also help inhibit peripheral T4 to T3 conversion. * **Burch-Wartofsky Point Scale:** Used clinically to diagnose and grade the severity of a thyroid storm.

Q: A 20-year-old female presents with a 9-month history of neck swelling and thyrotoxic symptoms. Investigations reveal increased T4 and decreased TSH levels, with a palpable 2 cm thyroid nodule. What is the next appropriate investigation?

Thyroid scan. ### **Explanation** The clinical presentation describes a patient with **overt hyperthyroidism** (increased T4, decreased TSH) and a **palpable thyroid nodule**. In the management of a thyroid nodule, the first step is always checking the TSH level. 1. **Why Thyroid Scan is correct:** When TSH is suppressed (low), the next step is a **Thyroid Radionuclide Scan** (using Technetium-99m or Iodine-123). This determines the functional status of the nodule. If the nodule is "hot" (autonomously functioning), the risk of malignancy is extremely low (<1%), and further evaluation with FNAC is generally not required. If the nodule is "cold" (non-functioning), the risk of malignancy is higher, and an Ultrasound-guided FNAC is indicated. 2. **Why Ultrasound is incorrect:** While USG is the most sensitive tool for anatomical characterization of nodules, in the presence of hyperthyroidism, functional assessment (Scan) takes precedence to avoid unnecessary biopsy of a hot nodule. 3. **Why Radioactive Iodine Uptake (RAIU) is incorrect:** RAIU measures the percentage of iodine trapped by the *entire* gland to differentiate causes of thyrotoxicosis (e.g., Graves' vs. Thyroiditis). It does not provide the localized "hot vs. cold" map required to evaluate a specific nodule. 4. **Why CT scan is incorrect:** CT is not a primary investigation for thyroid nodules and the iodinated contrast can interfere with subsequent radioactive iodine therapy. ### **Clinical Pearls for NEET-PG** * **The "Golden Rule":** Never perform FNAC on a "Hot" nodule. * **Hot Nodule:** High uptake; low risk of malignancy; treat the hyperthyroidism. * **Cold Nodule:** Low uptake; ~15-20% risk of malignancy; proceed to FNAC. * **Most common cause of a solitary hot nodule:** Toxic Adenoma (Plummer’s disease).

Q: Which of the following is true regarding a solitary thyroid nodule?

Common in females. ### Explanation **Correct Option: D. Common in females** Solitary thyroid nodules (STN) are clinically common, and epidemiological studies consistently show a higher prevalence in women. The female-to-male ratio for thyroid nodules is approximately **4:1**. While nodules are more frequent in females, it is a high-yield clinical fact that a solitary nodule found in a **male** or at the extremes of age (very young or very old) carries a significantly higher risk of malignancy. **Analysis of Incorrect Options:** * **A. Thyroid-stimulating hormone receptor antibodies (TRAb):** These antibodies are the hallmark of **Graves' Disease**, which typically presents with diffuse toxic goiter rather than a solitary nodule. * **B. Lined by columnar epithelium:** This is a histological feature often associated with **Papillary Thyroid Carcinoma** (tall cell variant) or toxic goiters (hyperactive follicles), but it is not a defining characteristic of a solitary nodule itself, which can be a cyst, adenoma, or various types of carcinoma. * **C. Diffuse hyperplasia of the thyroid:** This describes a **Diffuse Goiter** (e.g., Graves' or physiological goiter). A solitary nodule is, by definition, a discrete swelling in an otherwise impalpable gland or a prominent nodule in a multinodular goiter. **Clinical Pearls for NEET-PG:** * **Initial Investigation of Choice:** Serum TSH. * **Gold Standard Investigation:** Fine Needle Aspiration Cytology (FNAC). * **Most Common Cause:** Colloid nodule/Dominant nodule of a Multinodular Goiter (MNG). * **Risk of Malignancy:** Approximately 5–15% of solitary nodules are malignant. * **Hot vs. Cold Nodules:** On radionuclide scanning, "Cold" nodules (non-functional) have a higher risk of malignancy compared to "Hot" (hyperfunctioning) nodules.

Q: Pemberton’s sign is elicited by which maneuver?

Raising of arms. **Explanation:** **Pemberton’s sign** is a clinical maneuver used to demonstrate latent **thoracic inlet obstruction**. It is most commonly seen in patients with a large retrosternal goiter, though it can also occur in cases of mediastinal tumors or superior vena cava (SVC) syndrome. **1. Why "Raising of arms" is correct:** The maneuver involves asking the patient to elevate both arms until they touch the sides of the face (Pemberton’s maneuver) and holding this position for 30–60 seconds. This action further narrows the thoracic inlet by pulling the clavicles and soft tissues upward. In the presence of a retrosternal mass, this "corks" the inlet, obstructing venous return. A **positive sign** is indicated by facial congestion, cyanosis, inspiratory stridor, or distended neck veins. **2. Why the other options are incorrect:** * **Swallowing:** This is used to assess the mobility of a thyroid swelling (thyroid moves upward with deglutition due to its attachment to the pretracheal fascia). * **Extrusion of tongue:** This is used to identify a **Thyroglossal cyst**, which moves upward upon tongue protrusion because it is connected to the hyoid bone/foramen caecum. * **Extension of neck:** While extension can make a cervical goiter more prominent, it is not the specific maneuver for Pemberton’s sign. **Clinical Pearls for NEET-PG:** * **Indication:** Retrosternal goiter is the #1 cause. * **Mechanism:** Venous congestion due to compression of the internal jugular and subclavian veins. * **Berry’s Sign:** Absence of carotid pulse due to encasement by thyroid malignancy (differentiates from benign goiter). * **Kocher’s Test:** Pushing on the lateral lobes of a goiter causing stridor (indicates tracheomalacia or compression).

Q: A patient operated for thyroid surgery for a thyroid swelling, later in the evening developed difficulty in breathing and swelling in the neck. What is the immediate management?

Open the wound sutures in the ward. ### Explanation **Correct Option: D. Open the wound sutures in the ward** The clinical presentation of respiratory distress and neck swelling immediately following thyroid surgery is a classic sign of a **tension hematoma**. This is a surgical emergency where bleeding (usually from a slipped ligature on the superior thyroid artery) accumulates deep to the investing layer of the deep cervical fascia. The pressure compresses the trachea and causes venous congestion, leading to laryngeal edema and rapid airway obstruction. The **immediate management** is to evacuate the hematoma to relieve the pressure. This must be done at the bedside (in the ward) by removing the skin sutures and opening the deep fascia. Waiting to transfer the patient to the operating theater can be fatal. **Why other options are incorrect:** * **A. Epinephrine injection:** Used for anaphylaxis or cardiac arrest; it does not address the mechanical compression of the airway. * **B. Tracheostomy:** While it secures the airway, it is technically difficult and time-consuming in a patient with a massive neck hematoma. Hematoma evacuation must precede or bypass the need for this. * **C. IV calcium gluconate:** This is the treatment for hypocalcemia (post-operative tetany), which typically presents 24–72 hours post-surgery with circumoral paresthesia and carpopedal spasm, not acute respiratory distress. **Clinical Pearls for NEET-PG:** * **Most common cause of post-thyroidectomy respiratory distress:** Tension hematoma (within the first 24 hours). * **Other causes:** Bilateral recurrent laryngeal nerve injury (presents immediately after extubation) and laryngeal edema. * **Sequence of Management:** 1. Open sutures at bedside $\rightarrow$ 2. Secure airway (intubation) $\rightarrow$ 3. Return to OR for formal hemostasis. * **Tracheomalacia:** A rare cause of collapse seen in long-standing large goiters where tracheal rings have weakened.

Question 1

What is the best surgical approach for accessing a retrosternal goitre?

Accepted Answer

Cervical approach

Answer

Sternal approach

Answer

Sternal approach

Answer

VATS

Question 2

A 50-year-old female patient presented with a chief complaint of a painless thyroid nodule. Further examination is insignificant. TSH levels are normal. FNAC reveals papillary changes with nuclear atypia. Total thyroidectomy is planned. During surgery, a nearby nerve is injured while ligating the superior thyroid artery. Which of the following laryngeal muscles is likely to be affected?

Accepted Answer

Thyroarytenoid muscle

Answer

Cricothyroid muscle

Answer

Posterior cricoarytenoid muscle

Answer

Lateral cricoarytenoid muscle

Question 3

In retrosternal goiter, what is the most common presenting feature?

Accepted Answer

Dyspnea

Answer

Dysphagia

Answer

Stridor

Answer

Superior vena cava syndrome

Question 4

A 3 cm adrenal mass is found incidentally on a CT scan. Which of the following investigations is NOT indicated?

Accepted Answer

Adrenalectomy

Answer

Dexamethasone suppression test

Answer

Measurement of plasma catecholamines

Answer

Midnight plasma cortisol measurement

Question 5

A patient underwent thyroidectomy for hyperthyroidism. Two days later, the patient presented with features of thyroid storm. What is the most likely cause?

Accepted Answer

Inadequate preoperative preparation

Answer

Poor antibiotic coverage

Answer

Rough handling during surgery

Answer

Removal of parathyroid

Question 6

A 20-year-old female presents with a 9-month history of neck swelling and thyrotoxic symptoms. Investigations reveal increased T4 and decreased TSH levels, with a palpable 2 cm thyroid nodule. What is the next appropriate investigation?

Accepted Answer

Thyroid scan

Answer

Ultrasound

Answer

Radioactive iodine uptake

Answer

CT scan

Question 7

What is the treatment for parathyroid hyperplasia?

Accepted Answer

Removal of 3 1/2 glands

Answer

Phosphate binders

Answer

Calcitonin

Answer

Enlarged glands to be removed

Question 8

Which of the following is true regarding a solitary thyroid nodule?

Accepted Answer

Common in females

Answer

Thyroid-stimulating hormone receptor antibodies (THR-Ab)

Answer

Lined by columnar epithelium

Answer

Diffuse hyperplasia of the thyroid

Question 9

Pemberton’s sign is elicited by which maneuver?

Accepted Answer

Raising of arms

Answer

Swallowing

Answer

Extrusion of tongue

Answer

Extension of neck

Question 10

A patient operated for thyroid surgery for a thyroid swelling, later in the evening developed difficulty in breathing and swelling in the neck. What is the immediate management?

Accepted Answer

Open the wound sutures in the ward

Answer

Epinephrine injection

Answer

Tracheostomy

Answer

IV calcium gluconate

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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