Endocrine Surgery — MCQs
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Complications of therapy with radioactive iodine include?
A young lady presents with symptoms of hyperthyroidism, including elevated T4 and TSH levels. On examination, she is not experiencing tachycardia or excessive sweating. Further examination reveals bitemporal hemianopia. What is the next best step in management?
A 19-year-old female presents with neck pain for 5 days, making it difficult to wear a tie for her job. She reports a 10-day history of fatigue and lethargy, preceded by flu-like symptoms 20 days ago that resolved spontaneously. Her blood pressure is 110/80 mmHg, and her pulse is 48/min. Her extremities are cold and dry. The neck is very tender. An ECG is normal, TSH is elevated, and ESR is 30 mm/hr. What is the next appropriate step?
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?
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?
All of the following are superior mediastinal tumors except:
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 :
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?
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
Surgical treatment for a 40-years old lady with 3 x 3 cm. papillary carcinoma thyroid with level III enlarged lymph nodes is :
Endocrine Surgery Indian Medical PG Practice Questions and MCQs
Question 261: Complications of therapy with radioactive iodine include?
- A. Thyroid malignancy
- B. Hypothyroidism (Correct Answer)
- C. Leukemia
- D. All of the above
Explanation: **Explanation:** Radioactive Iodine (I-131) therapy is a definitive treatment for hyperthyroidism (Graves' disease and toxic multinodular goiter). **Why Hypothyroidism is the Correct Answer:** Hypothyroidism is the most common and expected long-term complication of I-131 therapy. The isotope emits **beta particles**, which cause progressive destruction of the thyroid follicular cells and subsequent fibrosis. The incidence of hypothyroidism is approximately 10-20% in the first year and continues at a rate of 2-3% annually thereafter. In many clinical protocols, permanent hypothyroidism is considered a therapeutic goal rather than a side effect, as it is easier to manage with levothyroxine than persistent hyperthyroidism. **Why Other Options are Incorrect:** * **Thyroid Malignancy & Leukemia:** Extensive long-term epidemiological studies (such as the Cooperative Thyrotoxicosis Therapy Follow-up Study) have shown **no significant increase** in the risk of thyroid cancer, leukemia, or other visceral malignancies in adults treated with standard doses of I-131 for hyperthyroidism. While high doses used for thyroid cancer may slightly increase secondary malignancy risk, it is not a standard complication for benign thyroid disease therapy. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** I-131 emits **Beta particles** (local tissue destruction, 0.5–2 mm range) and **Gamma rays** (used for imaging). * **Contraindications:** Pregnancy (absolute), breastfeeding, and severe Graves' ophthalmopathy (may worsen after therapy). * **Pre-treatment:** Patients should be rendered euthyroid with antithyroid drugs (ATDs) before I-131 to prevent **thyroid storm** due to radiation-induced thyroiditis. * **Monitoring:** Lifelong monitoring of TSH levels is mandatory post-therapy.
Question 262: A young lady presents with symptoms of hyperthyroidism, including elevated T4 and TSH levels. On examination, she is not experiencing tachycardia or excessive sweating. Further examination reveals bitemporal hemianopia. What is the next best step in management?
- A. Start beta-blockers immediately.
- B. Conservative management is sufficient.
- C. Start antithyroid drugs and wait for symptoms to resolve.
- D. Start antithyroid drugs and perform urgent MRI. (Correct Answer)
Explanation: ### Explanation **Concept Analysis:** The clinical presentation of elevated T4 accompanied by an inappropriately elevated (or non-suppressed) TSH is a classic indicator of **TSH-secreting Pituitary Adenoma (Thyrotropinoma)**. Unlike primary hyperthyroidism (Graves' disease), where TSH is suppressed, this is a form of secondary hyperthyroidism. The presence of **bitemporal hemianopia** confirms a mass effect on the optic chiasm, indicating a macroadenoma. **Why Option D is Correct:** The management of a TSH-oma requires a dual approach: 1. **Antithyroid drugs (ATDs):** These are necessary to achieve a euthyroid state and prevent a thyroid storm before any surgical intervention. 2. **Urgent MRI Brain/Pituitary:** This is the gold standard for visualizing the adenoma, assessing its size, and planning surgical decompression (transsphenoidal surgery), which is the definitive treatment. **Why Other Options are Incorrect:** * **Option A:** While beta-blockers are standard for primary hyperthyroidism, the patient specifically lacks tachycardia and sweating. More importantly, they do not address the compressive pituitary lesion. * **Option B:** Conservative management is contraindicated as the bitemporal hemianopia indicates active compression of the visual pathways, which can lead to permanent blindness. * **Option C:** Waiting for symptoms to resolve with ATDs alone is dangerous. While ATDs control the peripheral effects, they do not stop the growth of the pituitary tumor or relieve the pressure on the optic chiasm. **NEET-PG High-Yield Pearls:** * **Inappropriate TSH Secretion:** Always differentiate between TSH-oma and **Resistance to Thyroid Hormone (RTH)**. In RTH, there are usually no pressure symptoms (like hemianopia) and a positive family history. * **Visual Field Defect:** Bitemporal hemianopia = Optic Chiasm compression. * **First-line Treatment:** Transsphenoidal surgery is the treatment of choice for TSH-omas. Somatostatin analogues (Octreotide) can also be used to shrink the tumor and normalize TSH levels.
Question 263: A 19-year-old female presents with neck pain for 5 days, making it difficult to wear a tie for her job. She reports a 10-day history of fatigue and lethargy, preceded by flu-like symptoms 20 days ago that resolved spontaneously. Her blood pressure is 110/80 mmHg, and her pulse is 48/min. Her extremities are cold and dry. The neck is very tender. An ECG is normal, TSH is elevated, and ESR is 30 mm/hr. What is the next appropriate step?
- A. Atropine injection
- B. Levothyroxine administration
- C. Aspirin (Correct Answer)
- D. Increase iodine intake in food
Explanation: ### Explanation **Diagnosis: Subacute Granulomatous Thyroiditis (De Quervain’s Thyroiditis)** The clinical presentation of a young female with **severe neck tenderness**, a preceding **viral (flu-like) illness**, and an **elevated ESR** is classic for Subacute Thyroiditis. 1. **Why Aspirin is Correct:** Subacute thyroiditis is an inflammatory condition. The primary goal of treatment is pain relief and reducing inflammation. **NSAIDs (like Aspirin)** or Salicylates are the first-line treatment for mild-to-moderate cases. If the pain is severe or unresponsive to NSAIDs, corticosteroids (Prednisolone) are indicated. 2. **Why the other options are incorrect:** * **Atropine:** While the patient has bradycardia (48/min), it is a physiological consequence of her current hypothyroid state, not a primary cardiac conduction defect. Treating the underlying thyroid condition is the priority. * **Levothyroxine:** This patient is currently in the **hypothyroid phase** (elevated TSH, cold/dry skin, bradycardia) which follows the initial thyrotoxic phase. This phase is usually transient and self-limiting. Levothyroxine is only indicated if symptoms are severe or prolonged. * **Iodine intake:** Increasing iodine is used for nutritional deficiency goiters or to block thyroid hormone release (Wolff-Chaikoff effect) in Graves' disease, neither of which is relevant here. ### NEET-PG High-Yield Pearls * **Triphasic Course:** Hyperthyroid phase (due to release of stored hormone) → Hypothyroid phase → Euthyroid state. * **Key Diagnostic Marker:** Markedly elevated **ESR** (often >50 mm/hr) and low radioactive iodine uptake (**RAIU**) during the thyrotoxic phase. * **Pathology:** Histology shows **giant cells** and granulomatous inflammation. * **Management Rule:** Treat the symptoms (Pain = NSAIDs; Tachycardia = Beta-blockers). Anti-thyroid drugs (PTU/Methimazole) have **no role** because there is no excess synthesis of hormone.
Question 264: 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?
- A. External branch of the superior laryngeal nerve (EBSLN) (Correct Answer)
- B. Glossopharyngeal nerve
- C. Internal branch of the superior laryngeal nerve (IBSLN)
- D. Recurrent laryngeal nerve (RLN)
Explanation: ***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
Question 265: 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?
- A. Wait and watch.
- B. Radiotherapy
- C. Chemotherapy
- D. Radioactive iodine (RAI) ablation (Correct Answer)
Explanation: ***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
Question 266: All of the following are superior mediastinal tumors except:
- A. Thyroid
- B. Thymus
- C. Lymphoma
- D. Parathyroid (Correct Answer)
Explanation: ***Parathyroid*** - Parathyroid tumors are **not classic superior mediastinal tumors** - Ectopic parathyroid adenomas, when mediastinal, are typically located in the **anterior-inferior mediastinum**, not the superior mediastinum - They descend embryologically with the thymus from the 3rd pharyngeal pouch and are found in the **thymic tongue** or anterior mediastinum at lower levels - **Not part of the classic anterior/superior mediastinal mass differential** (the "4 Ts") *Thymus* - The thymus is the **primary organ** of the anterior and superior mediastinum - **Thymoma, thymic hyperplasia, and thymic carcinoma** are classic superior/anterior mediastinal tumors - Part of the "4 Ts" mnemonic: **Thymus**, Thyroid, Teratoma, Terrible lymphoma *Thyroid* - **Retrosternal (substernal) goiter** represents extension of cervical thyroid into the superior mediastinum - Common cause of superior mediastinal masses, especially in older patients - Can cause tracheal compression and superior vena cava syndrome - Part of the "4 Ts" of anterior mediastinal masses *Lymphoma* - **Lymphoma (especially Hodgkin lymphoma and T-cell lymphoblastic lymphoma)** is one of the most common anterior/superior mediastinal masses - Part of the "4 Ts": Thymus, Thyroid, Teratoma, and **"Terrible lymphoma"** - Typically presents as a large anterior mediastinal mass in young adults - May cause B symptoms (fever, night sweats, weight loss) and superior vena cava syndrome
Question 267: 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 :
- A. 1, 3 and 4 (Correct Answer)
- B. 1, 2 and 3
- C. 2, 3 and 4
- D. 1, 2 and 4
Explanation: ***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**.
Question 268: 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?
- A. Myxomatous transformation
- B. Haemorrhage
- C. Cystic degeneration
- D. Malignant transformation (Correct Answer)
Explanation: ***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.
Question 269: 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
- A. solitary thyroid nodule
- B. thyroglossal cyst with only functioning thyroid tissue (Correct Answer)
- C. thyroglossal cyst
- D. lateral aberrant thyroid
Explanation: ***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 270: Surgical treatment for a 40-years old lady with 3 x 3 cm. papillary carcinoma thyroid with level III enlarged lymph nodes is :
- A. Total thyroidectomy with radical neck dissection
- B. Total thyroidectomy with post-operative radio-iodine ablation
- C. Total thyroidectomy with excision of involved nodes
- D. Total thyroidectomy with functional neck dissection (Correct Answer)
Explanation: ***Total thyroidectomy with functional neck dissection*** - For **papillary thyroid carcinoma** with **level III lymph node involvement**, the standard approach is **total thyroidectomy** with **therapeutic lateral neck dissection** (functional/modified radical neck dissection). - **Level III nodes** are part of the **lateral compartment** (levels II-IV), requiring formal **compartment-oriented dissection** rather than selective node excision for adequate oncological clearance. *Total thyroidectomy with excision of involved nodes* - **"Excision of involved nodes"** is not standard terminology in thyroid surgery and **"berry-picking"** individual nodes is generally not recommended for therapeutic purposes. - **Compartment-oriented dissection** is preferred over selective node removal as it provides better oncological outcomes and staging accuracy. *Total thyroidectomy with radical neck dissection* - **Radical neck dissection** involves removal of cervical lymph node levels I-V along with the **sternocleidomastoid muscle**, **internal jugular vein**, and **spinal accessory nerve**. - This extensive procedure is reserved for cases with **extensive extranodal extension** or when these structures are directly involved, causing significant morbidity. *Total thyroidectomy with post-operative radio-iodine ablation* - **Radioiodine ablation** is an **adjuvant therapy** used after thyroidectomy to destroy remaining thyroid tissue and microscopic disease. - This option doesn't address the **surgical management** of enlarged lymph nodes, which is specifically what the question asks about.
Practice by Chapter
Thyroid Nodules
Practice Questions
Thyroid Cancer
Practice Questions
Graves' Disease
Practice Questions
Thyroiditis
Practice Questions
Primary Hyperparathyroidism
Practice Questions
Secondary and Tertiary Hyperparathyroidism
Practice Questions
Adrenal Cortical Tumors
Practice Questions
Pheochromocytoma
Practice Questions
Adrenal Incidentalomas
Practice Questions
Multiple Endocrine Neoplasia
Practice Questions
Neuroendocrine Tumors
Practice Questions
Intraoperative Monitoring in Endocrine Surgery
Practice Questions
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