Endocrine Surgery — MCQs

Endocrine Surgery Indian Medical PG Practice Questions and MCQs

Question 281: Which of the following statements is true regarding retrosternal goiters?

A. Majority of the goiters derive their blood supply from mediastinal vessels
B. Sternal incision is required in all cases
C. Surgery is performed only if the patient is symptomatic
D. Most retrosternal goiters can be removed through a neck incision (Correct Answer)

Explanation: ***Most retrosternal goiters can be removed through a neck incision*** - The majority of retrosternal goiters, even those extending significantly into the mediastinum, originate from cervical thyroid tissue and can be safely delivered through a standard **cervical incision**. - While careful dissection is required to free the mass from surrounding mediastinal structures, **rarely is a sternotomy** or thoracotomy needed. *Majority of the goiters derive their blood supply from mediastinal vessels* - Retrosternal goiters typically maintain their primary **blood supply from the superior and inferior thyroid arteries**, which are cervical vessels. - While some small accessory vessels might come from the mediastinum, the bulk of the vascularization remains **cervical in origin**. *Sternal incision is required in all cases* - A **sternal incision (sternotomy)** is required in only a small percentage (less than 10%) of retrosternal goiter cases, usually for very large, highly adherent, or recurrent goiters, or suspicion of malignancy. - The goal is always to avoid a sternotomy due to its increased morbidity and recovery time compared to a cervical approach. *Surgery is performed only if the patient is symptomatic* - Surgery for retrosternal goiters is often recommended even in **asymptomatic patients** due to the risk of future complications, such as airway compromise, superior vena cava syndrome, or malignancy. - The potential for growth and compression of vital mediastinal structures makes prophylactic surgery a common consideration.

Question 282: Most commonly used approach for retrosternal goitre:-

A. Transthoracic second intercostal space
B. Axillary approach
C. Trans-sternal through anterior mediastinum
D. Transcervical (Correct Answer)

Explanation: ***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.

Question 283: Most common cause of recurrent laryngeal nerve palsy is:

A. Mediastinal tumors
B. Thyroid surgery (Correct Answer)
C. Bronchogenic carcinoma
D. Pancoast tumor

Explanation: ***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.

Question 284: A 45-year-old develops dysphagia 3 months post thyroidectomy. Most likely cause?

A. Recurrent tumor
B. RLN palsy
C. Adhesions (Correct Answer)
D. Esophageal injury

Explanation: ***Adhesions*** - **Adhesions** are the **most common cause** of delayed dysphagia occurring 3 months post-thyroidectomy. - **Perithyroidal and periesophageal adhesions** develop as part of the healing process and can cause esophageal compression, restriction of laryngotracheal mobility, or tethering of the esophagus. - The **3-month timeline** is classic for scar tissue maturation and adhesion formation, which peaks between 2-6 months post-operatively. - Patients typically describe **mechanical dysphagia** (difficulty with solid foods initially) and a sensation of tightness or fullness in the neck. - Management is usually **conservative** with time and reassurance, though severe cases may require surgical adhesiolysis. *Esophageal injury* - **Esophageal injury** during thyroidectomy is **extremely rare** (<0.1% incidence) due to the anatomical plane of dissection. - If it occurs, it typically presents **immediately or within days** post-operatively with severe symptoms such as fever, mediastinitis, subcutaneous emphysema, chest pain, and sepsis. - A **3-month delayed presentation** would be highly unusual and not the "most likely" cause in this clinical scenario. *RLN palsy* - **Recurrent laryngeal nerve (RLN) palsy** causes **hoarseness and voice changes** due to vocal cord paralysis, not dysphagia. - While bilateral RLN injury can cause airway obstruction and aspiration, it does not typically cause true dysphagia (difficulty swallowing solids/liquids). - RLN palsy manifests **immediately post-operatively** when the patient is extubated, not months later. *Recurrent tumor* - **Recurrent thyroid cancer** causing dysphagia at 3 months post-operatively is **extremely unlikely**. - Tumor recurrence typically takes **months to years** to develop and would be accompanied by other findings such as a palpable neck mass, lymphadenopathy, or recurrent laryngeal nerve involvement. - The short time frame makes this diagnosis improbable unless dealing with anaplastic carcinoma, which is rare.

Question 285: Which is a known complication of thyroid surgery?

A. Hypercalcemia
B. Hypocalcemia (Correct Answer)
C. Hypoglycemia
D. Hyperkalemia

Explanation: ***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.

Question 286: Which nerve is most likely injured during a thyroidectomy?

A. Hypoglossal
B. Phrenic nerve
C. Superior laryngeal
D. Recurrent laryngeal (Correct Answer)

Explanation: ***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.

Question 287: During thyroidectomy, damage to which nerve leads to loss of high-pitched voice?

A. External branch of the superior laryngeal nerve (Correct Answer)
B. Hypoglossal nerve
C. Vagus nerve
D. Recurrent laryngeal nerve

Explanation: ***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.

Question 288: For a patient with multiple endocrine neoplasia type 1 (MEN1) and primary hyperparathyroidism, how do you determine the extent of parathyroid surgery?

A. Surgery is not indicated in genetic cases
B. Decision based solely on serum calcium levels
C. The extent of surgery is determined by the number of glands involved and specific genetic study results.
D. All patients undergo total parathyroidectomy with autotransplantation (Correct Answer)

Explanation: **All patients undergo total parathyroidectomy** - Total parathyroidectomy is recommended in MEN1 primary hyperparathyroidism to prevent recurrent hyperparathyroidism due to the underlying **multiglandular hyperplasia**. - The remaining parathyroid tissue (usually a portion of one gland) is then **autotransplanted** into a muscle, typically of the forearm, to allow for easier access if another surgery is needed, while still maintaining some parathyroid function. *Surgery is not indicated in genetic cases* - This statement is incorrect; surgical intervention is often necessary for managing **hyperparathyroidism in MEN1** to control hypercalcemia and prevent its complications. - While MEN1 is a genetic disorder, the resulting endocrine tumors often require active management including **surgical resection**. *Decision based solely on serum calcium levels* - While serum calcium levels are crucial for diagnosing and monitoring hyperparathyroidism, the *extent* of surgery in MEN1 is not determined solely by these levels. - MEN1 hyperparathyroidism invariably involves **multiglandular hyperplasia**, necessitating a more comprehensive surgical approach than in sporadic primary hyperparathyroidism. *The extent of surgery is determined by the number of glands involved and specific genetic study results.* - In MEN1, the typical presentation is **multiglandular hyperplasia**, meaning all four parathyroid glands are usually affected, making the **number of involved glands** a less variable factor. - While genetic studies confirm the diagnosis of MEN1, they don't dictate the surgical *extent* for parathyroidectomy, which remains total parathyroidectomy with autotransplantation due to the diffuse nature of the disease.

Question 289: In a patient undergoing thyroid surgery, which complication is associated with injury to the recurrent laryngeal nerve?

A. Dysphagia
B. Stridor (Correct Answer)
C. Hypocalcemia
D. Hypertension

Explanation: ***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 290: A 30-year-old woman presents with hypercalcemia and kidney stones. Imaging reveals a thyroid mass, and histology shows spindle cells and amyloid deposits within the tumor. How would you manage this condition?

A. Total thyroidectomy (Correct Answer)
B. Chemotherapy with targeted therapy
C. Radiation therapy to the thyroid
D. Observation with serial ultrasound

Explanation: ***Total thyroidectomy*** - Given the presence of a thyroid mass with **hypercalcemia** and **distinct histological findings**, a total thyroidectomy is indicated to remove the tumor completely [1]. - This approach addresses the potential for malignancy and prevents further complications such as hypercalcemia and kidney stones. *Observation with serial ultrasound* - Not appropriate due to the **presence of hypercalcemia** and the **thyroid mass**, which raises concern for malignancy. - Delaying intervention could lead to worsening symptoms and complications. *Radiation therapy to the thyroid* - Typically utilized for **postoperative management** or in the presence of **differentiated thyroid carcinoma**, not as a primary treatment for a suspicious thyroid mass. - It does not address the mass directly and may not alleviate the immediate symptoms of hypercalcemia. *Chemotherapy with targeted therapy* - Not indicated for thyroid tumors unless it is clearly a **dedifferentiated or advanced carcinoma**. - There is insufficient evidence to suggest chemotherapy is effective for the management of thyroid masses with associated hypercalcemia. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1102-1103.

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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