Endocrine Surgery Practice Questions

Q: Most commonly used approach for retrosternal goitre:-

Transcervical. ***Transcervical*** - The transcervical approach is the **most common and preferred method** for resecting retrosternal goitres, as the majority can be delivered through the **thoracic inlet**. - This approach minimizes morbidity and avoids the need for a **sternotomy** in most cases. *Transthoracic second intercostal space* - This approach is typically reserved for **mediastinal masses** or procedures requiring direct access to the **pleural cavity**, which is generally not necessary for retrosternal goitres. - It would involve a more invasive incision than typically required for a goitre that can be delivered transcervically. *Axillary approach* - The axillary approach is primarily used for **lymph node dissection** in breast cancer or for certain **thoracoscopic procedures**, not for accessing the thyroid gland for retrosternal goitre removal. - Its anatomical location does not provide adequate exposure to the **cervical and mediastinal structures** involved in a retrosternal goitre. *Trans-sternal through anterior mediastinum* - A trans-sternal approach (sternotomy) is a **major surgical procedure** typically reserved for very large, irreducible retrosternal goitres that have significant **mediastinal extension** or are adherent to surrounding structures. - It is avoided whenever possible due to increased morbidity and longer recovery compared to the transcervical approach, making it less commonly used overall.

Q: Most common cause of recurrent laryngeal nerve palsy is:

Thyroid surgery. ***Thyroid surgery*** - **Iatrogenic injury** during **thyroid surgery** (thyroidectomy) is the most common cause of recurrent laryngeal nerve palsy due to the proximity of the nerve to the thyroid gland. - The nerve can be stretched, ligated, or transected during the procedure, leading to vocal cord paralysis. *Mediastinal tumors* - While mediastinal tumors can cause recurrent laryngeal nerve palsy by **compressing or invading the nerve**, this is less common than iatrogenic injury during thyroid surgery. - The left recurrent laryngeal nerve is particularly vulnerable due to its longer course through the mediastinum. *Bronchogenic carcinoma* - **Bronchogenic carcinoma**, especially those in the apex of the lung or near the aortic arch, can invade or compress the recurrent laryngeal nerve, causing palsy. - However, this is primarily a cause in specific, advanced cancer cases and not the most common overall cause. *Pancoast tumor* - A **Pancoast tumor** (a type of bronchogenic carcinoma in the lung apex) can cause recurrent laryngeal nerve palsy, particularly on the left side, due to local invasion. - While a specific cause of nerve palsy, it is a less frequent cause compared to surgical injury to the thyroid gland.

Q: Which is a known complication of thyroid surgery?

Hypocalcemia. ***Hypocalcemia*** - This is a common complication due to potential **accidental removal** or **damage to the parathyroid glands** during thyroidectomy. - The parathyroid glands regulate **calcium levels**, and their impairment leads to decreased parathyroid hormone (PTH) secretion, causing hypocalcemia. *Hypercalcemia* - This is an **elevated calcium level**, which is generally not a complication of thyroid surgery itself. - It would more commonly be associated with conditions like **primary hyperparathyroidism**. *Hypoglycemia* - This is a condition of **low blood glucose**, which is not directly related to thyroid surgery. - It is typically associated with conditions affecting **insulin regulation**, such as diabetes mellitus. *Hyperkalemia* - This refers to **elevated potassium levels** in the blood, which is not a typical complication of thyroid surgery. - It is more commonly seen in conditions like **renal failure** or certain medication side effects.

Q: Which nerve is most likely injured during a thyroidectomy?

Recurrent laryngeal. ***Recurrent laryngeal*** - The **recurrent laryngeal nerves** are highly susceptible to injury during thyroidectomy due to their close anatomical proximity to the **thyroid gland** and their relatively superficial course within the operative field. - Injury to these nerves can lead to **vocal cord paralysis**, resulting in **hoarseness** or, in cases of bilateral injury, severe airway compromise. *Hypoglossal* - The **hypoglossal nerve** (CN XII) innervates the muscles of the tongue and is located more superiorly and medially, well outside the typical dissection planes for a thyroidectomy. - Damage to this nerve would primarily affect **tongue movement** and speech articulation, symptoms not commonly associated with thyroid surgery complications. *Phrenic nerve* - The **phrenic nerve** innervates the diaphragm and is situated deep in the neck and thorax, far from the thyroid surgical field. - Injury during thyroidectomy is extremely rare and would lead to **diaphragmatic paralysis**, causing respiratory difficulties. *Superior laryngeal* - The **superior laryngeal nerve** descends alongside the superior thyroid artery and typically divides into internal and external branches; the **external branch** is at risk during ligation of the superior thyroid pedicle. - While it can be injured, the **recurrent laryngeal nerve** is more frequently and severely affected, particularly its motor function to the intrinsic laryngeal muscles, which is most critical for voice production.

Q: During thyroidectomy, damage to which nerve leads to loss of high-pitched voice?

External branch of the superior laryngeal nerve. ***External branch of the superior laryngeal nerve*** - The **external branch of the superior laryngeal nerve** innervates the **cricothyroid muscle**, which is responsible for tensing the vocal cords. - Damage to this nerve paralyzes the cricothyroid muscle, leading to an inability to tense the vocal cords, resulting in a **monotonous voice** and **loss of high-pitched tones**. *Hypoglossal nerve* - The **hypoglossal nerve (CN XII)** controls the muscles of the **tongue**, affecting articulation and swallowing, but not vocal pitch directly. - Damage primarily causes **tongue deviation** and **difficulty with speech (dysarthria)** and swallowing. *Vagus nerve* - The **vagus nerve (CN X)** gives rise to both the **superior laryngeal nerve** and the **recurrent laryngeal nerve**. - While damage to the vagus nerve trunk would affect vocalization, the question specifically asks about loss of high-pitched voice, which points to a more localized injury to one of its branches. *Recurrent laryngeal nerve* - The **recurrent laryngeal nerve** innervates most of the intrinsic laryngeal muscles, including the **thyroarytenoid** and **posterior cricoarytenoid muscles**, primarily affecting vocal cord adduction and abduction. - Damage typically causes **hoarseness** due to vocal cord paralysis, and in severe cases, difficulty breathing, but it does not specifically lead to the *loss of high-pitched voice* as directly as superior laryngeal nerve damage.

Q: In a patient undergoing thyroid surgery, which complication is associated with injury to the recurrent laryngeal nerve?

Stridor. ***Stridor*** - Injury to the recurrent laryngeal nerve can lead to **vocal cord paralysis**, causing narrowing of the airway and producing a high-pitched, harsh sound known as **stridor**. - **Bilateral recurrent laryngeal nerve injury** is particularly dangerous as it can cause complete airway obstruction due to paralysis of both vocal cords in the adducted position. - Stridor is the **most characteristic and serious** complication of RLN injury requiring immediate management. *Dysphagia* - While **RLN injury can cause some swallowing difficulties** due to impaired glottic closure and aspiration risk, dysphagia is **not the most specific complication** of RLN injury. - **Superior laryngeal nerve injury** causes more prominent dysphagia by affecting the cricothyroid muscle and sensory innervation of the larynx. - Compared to stridor, dysphagia is a less specific finding for RLN injury and not the primary concern. *Hypocalcemia* - **Hypocalcemia** is a common complication of thyroid surgery caused by accidental removal or damage to the **parathyroid glands**, which are located near the thyroid. - The **parathyroid glands** regulate calcium levels in the blood, and their dysfunction leads to decreased parathyroid hormone production. - This is unrelated to nerve injury. *Hypertension* - **Hypertension** is not a direct or recognized complication of recurrent laryngeal nerve injury during thyroid surgery. - It might occur as a transient response to surgical stress or pain, but it is not linked to RLN damage.

Question 1

Which of the following statements is true regarding retrosternal goiters?

Accepted Answer

Most retrosternal goiters can be removed through a neck incision

Answer

Majority of the goiters derive their blood supply from mediastinal vessels

Answer

Sternal incision is required in all cases

Answer

Surgery is performed only if the patient is symptomatic

Question 2

Most commonly used approach for retrosternal goitre:-

Accepted Answer

Transcervical

Answer

Transthoracic second intercostal space

Answer

Axillary approach

Answer

Trans-sternal through anterior mediastinum

Question 3

Most common cause of recurrent laryngeal nerve palsy is:

Accepted Answer

Thyroid surgery

Answer

Mediastinal tumors

Answer

Bronchogenic carcinoma

Answer

Pancoast tumor

Question 4

A 45-year-old develops dysphagia 3 months post thyroidectomy. Most likely cause?

Accepted Answer

Adhesions

Answer

Recurrent tumor

Answer

RLN palsy

Answer

Esophageal injury

Question 5

Which is a known complication of thyroid surgery?

Accepted Answer

Hypocalcemia

Answer

Hypercalcemia

Answer

Hypoglycemia

Answer

Hyperkalemia

Question 6

Which nerve is most likely injured during a thyroidectomy?

Accepted Answer

Recurrent laryngeal

Answer

Hypoglossal

Answer

Phrenic nerve

Answer

Superior laryngeal

Question 7

During thyroidectomy, damage to which nerve leads to loss of high-pitched voice?

Accepted Answer

External branch of the superior laryngeal nerve

Answer

Hypoglossal nerve

Answer

Vagus nerve

Answer

Recurrent laryngeal nerve

Question 8

For a patient with multiple endocrine neoplasia type 1 (MEN1) and primary hyperparathyroidism, how do you determine the extent of parathyroid surgery?

Accepted Answer

All patients undergo total parathyroidectomy with autotransplantation

Answer

Surgery is not indicated in genetic cases

Answer

Decision based solely on serum calcium levels

Answer

The extent of surgery is determined by the number of glands involved and specific genetic study results.

Question 9

In a patient undergoing thyroid surgery, which complication is associated with injury to the recurrent laryngeal nerve?

Accepted Answer

Stridor

Answer

Dysphagia

Answer

Hypocalcemia

Answer

Hypertension

Question 10

A 25-year-old woman has a 4 cm thyroid nodule that is suspicious for cancer. What is the best next step in management?

Accepted Answer

Lobectomy

Answer

Radioactive iodine

Answer

Observation

Answer

Total thyroidectomy

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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