Endocrine Surgery — MCQs

Endocrine Surgery Indian Medical PG Practice Questions and MCQs

Question 291: A 25-year-old woman has a 4 cm thyroid nodule that is suspicious for cancer. What is the best next step in management?

A. Radioactive iodine
B. Observation
C. Lobectomy (Correct Answer)
D. Total thyroidectomy

Explanation: ***Lobectomy*** - For a **4 cm thyroid nodule** suspicious for cancer, **lobectomy** (hemithyroidectomy) is a reasonable initial surgical approach, particularly when the diagnosis is not yet confirmed. - Lobectomy allows for **definitive pathological diagnosis** while preserving thyroid function on the contralateral side. - If malignancy is confirmed, a **completion thyroidectomy** can be performed as a second procedure if indicated. - This approach is appropriate for **unilateral disease** with no concerning features suggesting bilateral involvement. - **Note:** Current guidelines increasingly favor total thyroidectomy for nodules ≥4 cm, but lobectomy remains an acceptable option in select cases. *Radioactive iodine* - This therapy is used for **hyperthyroidism** (e.g., toxic nodular goiter) or as **adjuvant treatment** for differentiated thyroid cancer **after total thyroidectomy**, not as initial management for a suspicious nodule. - Radioactive iodine cannot be used without a confirmed diagnosis and requires near-total or total thyroidectomy for optimal efficacy in cancer treatment. - Administering radioactive iodine without surgical staging would be inappropriate. *Observation* - **Observation** is reserved for **small, low-risk nodules** (<1 cm) with benign cytology or for patients with **significant comorbidities** precluding surgery. - A **4 cm nodule** with suspicious features warrants **prompt surgical intervention**, not observation. - Observation would risk disease progression and missed opportunity for early treatment if malignancy is present. *Total thyroidectomy* - While **total thyroidectomy** is increasingly preferred for **nodules ≥4 cm**, especially with high suspicion for malignancy, it represents a more extensive initial procedure. - Total thyroidectomy is clearly indicated for: **confirmed malignancy**, **bilateral disease**, **multifocal tumors**, or **aggressive histology**. - The advantage is avoiding a second surgery if cancer is confirmed, facilitating radioactive iodine therapy, and enabling thyroglobulin monitoring. - However, without confirmed malignancy, some surgeons prefer **lobectomy first** to establish diagnosis, especially if the nodule appears unilateral and the patient is low-risk.

Question 292: A patient presents with difficulty swallowing (dysphagia) and hoarseness of voice following a thyroidectomy. Damage to which nerve is most likely responsible for these symptoms?

A. Hypoglossal nerve
B. Vagus nerve
C. Glossopharyngeal nerve
D. Recurrent laryngeal nerve (RLN) (Correct Answer)

Explanation: ***Recurrent laryngeal nerve (RLN)*** - The **RLN** innervates most intrinsic laryngeal muscles, which are crucial for **vocalization** and **swallowing coordination**. - Injury to the RLN during thyroidectomy is a common complication, leading to **hoarseness of voice** (due to vocal cord paresis/paralysis) and **dysphagia** (due to impaired glottic closure during swallowing). *Hypoglossal nerve* - The **hypoglossal nerve (CN XII)** primarily controls the **tongue muscles**, affecting speech articulation and food manipulation within the mouth. - Damage would typically cause **tongue deviation** and difficulty with speech, rather than primary hoarseness or dysphagia related to vocal cord function. *Vagus nerve* - While the **vagus nerve (CN X)** is the parent nerve of the RLN, direct damage to the main vagus trunk (e.g., above the origin of the RLN) would cause more widespread dysfunction. - This would include a broader range of autonomic and motor deficits, such as difficulties with taste, gag reflex, and potentially more severe swallowing problems, but not specifically isolated hoarseness and dysphagia as seen here. *Glossopharyngeal nerve* - The **glossopharyngeal nerve (CN IX)** is involved in the **gag reflex**, taste from the posterior tongue, and sensation from the pharynx. - Damage typically results in loss of gag reflex, impaired taste, and difficulty initiating swallowing (impairment of the pharyngeal phase), but less directly in hoarseness related to vocal cord function.

Question 293: For a patient undergoing thyroidectomy for papillary thyroid cancer, how should the extent of lymph node dissection be determined?

A. Based on preoperative ultrasound and intraoperative findings (Correct Answer)
B. Remove all cervical lymph nodes without consideration of findings
C. Only perform lymph node dissection if nodes are clinically palpable and visible on imaging
D. Decision based on postoperative pathology of the primary tumor

Explanation: ***Based on preoperative ultrasound and intraoperative findings*** - Preoperative **ultrasound** can identify suspicious lymph nodes in the central and lateral neck, guiding the extent of dissection. - **Intraoperative findings**, such as visible or palpable metastatic nodes, further refine the need for and extent of lymph node dissection. - This is the **standard approach** recommended by ATA guidelines for therapeutic lymph node dissection. *Remove all cervical lymph nodes without consideration of findings* - This approach is overly aggressive and would lead to **unnecessary morbidity**, including potential nerve damage (recurrent laryngeal nerve injury, hypoparathyroidism), for many patients without nodal metastasis. - **Prophylactic comprehensive lymph node dissection** in the absence of evidence of metastasis is generally not recommended routinely for all papillary thyroid cancer patients. *Only perform lymph node dissection if nodes are clinically palpable and visible on imaging* - While palpable nodes and visible findings on imaging are strong indicators, this approach may miss **micrometastases** or small nodal disease not clearly visible on routine imaging. - A more thorough evaluation using **high-resolution ultrasound** and potentially **fine-needle aspiration (FNA)** for suspicious nodes is often necessary, and therapeutic dissection should be performed when indicated even for non-palpable disease. *Decision based on postoperative pathology of the primary tumor* - The extent of lymph node dissection must be **decided intraoperatively**, not postoperatively. - While postoperative pathology may guide decisions about **completion surgery** or adjuvant therapy, it cannot inform the initial surgical approach to lymph nodes during thyroidectomy. - Waiting for final pathology would require a second operation if lymph node dissection is ultimately needed.

Question 294: A 22-year-old female with a thyroid nodule undergoes surgery. Which nerve is at risk of damage, potentially resulting in hoarseness?

A. Vagus nerve
B. Recurrent laryngeal nerve (Correct Answer)
C. Hypoglossal nerve
D. Accessory nerve

Explanation: ***Recurrent laryngeal nerve*** - The **recurrent laryngeal nerve (RLN)** innervates **most intrinsic muscles of the larynx**, which are responsible for **vocal cord movement**. - Due to its **close anatomical proximity** to the thyroid gland, especially near the **inferior thyroid artery**, it is highly susceptible to injury during thyroid surgery. - RLN injury leads to **vocal cord paralysis**, resulting in **hoarseness** (unilateral injury) or **aphonia and stridor** (bilateral injury). - This is the **most common nerve injury** in thyroid surgery. *Vagus nerve* - While the **vagus nerve (CN X)** is the parent nerve from which the RLN branches, damage to the vagus nerve in the neck above the RLN origin would cause more widespread symptoms. - Direct vagal injury would affect **pharyngeal and soft palate function**, not isolated hoarseness. - The vagus nerve runs more laterally and is less intimately involved with thyroid dissection compared to the RLN. *Hypoglossal nerve* - The **hypoglossal nerve (CN XII)** controls the **movements of the tongue**. - Damage would result in **tongue deviation** and difficulties with speech articulation (dysarthria) and swallowing, not hoarseness. - Its location is more **superior and lateral** to the thyroid gland, making it less vulnerable during thyroid surgery. *Accessory nerve* - The **accessory nerve (CN XI)** innervates the **sternocleidomastoid** and **trapezius muscles**. - Injury causes **shoulder drooping** or weakness in neck turning, completely unrelated to vocal cord function or hoarseness. - This nerve is located **posterolaterally** in the neck and is not at risk during standard thyroidectomy.

Question 295: A patient undergoes a thyroidectomy and presents postoperatively with tingling in the hands and around the mouth. What is the likely cause?

A. Hypocalcemia due to accidental removal of parathyroid glands (Correct Answer)
B. Thyroid storm
C. Hypoglycemia
D. Surgical site infection

Explanation: ***Hypocalcemia due to accidental removal of parathyroid glands*** - **Tingling in the hands and circumoral paresthesia** are classic symptoms of **hypocalcemia**, which is a common complication of thyroidectomy due to inadvertent removal or damage to the **parathyroid glands**. - The parathyroid glands are essential for **calcium homeostasis**, and their removal leads to a rapid drop in serum calcium levels. *Thyroid storm* - Thyroid storm is a **life-threatening exacerbation of hyperthyroidism** characterized by fever, tachycardia, delirium, and GI symptoms, none of which are primarily described here. - It typically occurs in patients with **untreated or inadequately treated hyperthyroidism**, not directly as a result of thyroidectomy unless there was severe pre-existing disease. *Hypoglycemia* - Hypoglycemia presents with symptoms such as **sweating, tremors, palpitations, and altered mental status**, which are distinct from the tingling described. - It is generally related to **insulin levels** or inadequate glucose intake and is not a direct complication of thyroidectomy. *Surgical site infection* - A surgical site infection would typically manifest with **fever, localized pain, redness, swelling, and purulent discharge** from the surgical wound, which are absent in this presentation. - Symptoms of infection generally appear later in the postoperative period than the acute neurological symptoms of hypocalcemia.

Question 296: A 40-year-old woman with a thyroid nodule undergoes a fine-needle aspiration biopsy that reveals orphan Annie eye nuclei. What is the most appropriate next step in management?

A. Core needle biopsy
B. Repeat FNA with molecular analysis
C. Radioactive iodine uptake scan
D. Lobectomy with histopathology (Correct Answer)

Explanation: ***Lobectomy with histopathology*** - A lobectomy provides a definitive diagnosis through **histopathological examination**, which can distinguish between benign and malignant thyroid lesions [1,2]. - This surgical approach allows for accurate assessment of the **tumor's architecture** and cellular characteristics, confirming the presence of malignancy if present [2,3]. *Radioactive iodine uptake scan* - Primarily used to assess **thyroid function** rather than determine malignancy in thyroid nodules. - It helps differentiate between **hyperfunctioning** and **hypofunctioning** nodules but does not provide tissue diagnosis. *Core needle biopsy* - While a core needle biopsy provides larger tissue samples than FNA, it is still less definitive than lobectomy for assessing **malignancy**. - In some cases, it might miss important features that require surgical review. *Repeat FNA with molecular analysis* - Although can give additional insights, it may not provide a definitive diagnosis since FNA results can still be ambiguous. - The presence of **Orphan Annie eye nuclei** suggests possible malignancy, necessitating a more conclusive **surgical intervention** [1,2]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 429-430. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, p. 1099. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, pp. 1099-1100.

Question 297: A 40-year-old woman with a history of hyperthyroidism undergoes a thyroidectomy. She develops tingling and muscle cramps postoperatively. What complication should be investigated?

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

Explanation: ***Hypocalcemia*** - **Tingling** (paresthesias) and **muscle cramps** are classic symptoms of hypocalcemia, which can occur due to accidental removal or damage to the **parathyroid glands** during thyroidectomy. - The parathyroid glands regulate **calcium levels**, and their compromise leads to decreased parathyroid hormone (PTH) production and subsequent low serum calcium. *Hypercalcemia* - This condition involves **elevated calcium levels** and would typically present with symptoms like fatigue, constipation, polyuria, and bone pain, which are not described. - Hypercalcemia is generally not a direct complication of thyroidectomy. *Hyperthyroidism* - This patient had a thyroidectomy to treat hyperthyroidism, so developing **worsening hyperthyroidism** post-surgery is highly unlikely. - Symptoms of hyperthyroidism include palpitations, weight loss, and heat intolerance, not tingling or muscle cramps. *Hypoglycemia* - Hypoglycemia relates to **low blood sugar** and typically causes symptoms like confusion, tremors, sweating, and weakness. - It is not a direct complication of thyroidectomy and is unrelated to calcium metabolism.

Question 298: A patient who underwent thyroidectomy experiences a drop in calcium levels post-operatively. What is the most likely cause?

A. Thyroid storm
B. Hypoparathyroidism (Correct Answer)
C. Laryngeal nerve damage
D. Thyroid cancer metastasis

Explanation: ***Hypoparathyroidism*** - The **parathyroid glands**, located adjacent to or within the thyroid gland, regulate calcium levels through **parathyroid hormone (PTH)**. - During thyroidectomy, these glands can be **inadvertently damaged, devascularized, or removed**, leading to insufficient PTH production. - This results in **postoperative hypocalcemia**, the most common cause of low calcium after thyroid surgery. - Typically presents within **24-48 hours** post-operatively with symptoms like perioral numbness, paresthesias, and tetany. *Thyroid storm* - A rare, life-threatening complication of **severe hyperthyroidism** characterized by fever, tachycardia, and altered mental status. - Does **not cause hypocalcemia**; may occasionally cause hypercalcemia due to increased bone turnover. - Unrelated to calcium metabolism or parathyroid function. *Laryngeal nerve damage* - Injury to the **recurrent laryngeal nerve** causes **vocal cord paralysis** and hoarseness. - Does **not affect calcium levels** or parathyroid gland function. - A distinct surgical complication unrelated to calcium metabolism. *Thyroid cancer metastasis* - Metastatic disease does **not cause acute postoperative hypocalcemia**. - While bone metastases can affect calcium levels chronically, this is not relevant to immediate post-thyroidectomy hypocalcemia. - The primary concern postoperatively is iatrogenic parathyroid injury, not cancer spread.

Question 299: A 48-year-old woman with a thyroid nodule and elevated calcitonin levels undergoes surgery. Postoperatively, she develops hypocalcemia. What is the likely cause?

A. Thyroid storm
B. Parathyroid gland injury (Correct Answer)
C. Insufficient calcium supplementation
D. Secondary hypothyroidism

Explanation: ***Parathyroid gland injury*** - Hypocalcemia after thyroid surgery, especially in the context of elevated calcitonin (suggesting **medullary thyroid carcinoma**), points to **inadvertent damage or removal** of the parathyroid glands during surgery. - The parathyroid glands are responsible for producing **parathyroid hormone (PTH)**, which regulates serum calcium levels, so their injury directly leads to hypocalcemia. - This is the **most common cause** of postoperative hypocalcemia after total thyroidectomy. *Thyroid storm* - **Thyroid storm** is a severe form of hyperthyroidism, characterized by fever, tachycardia, and altered mental status, and does not directly cause hypocalcemia. - While it's a potential complication of thyroid surgery, its symptoms are distinct from **hypocalcemia**. *Insufficient calcium supplementation* - This is a **management issue** rather than the **primary cause** of postoperative hypocalcemia. - **Calcium supplementation** is given to treat hypocalcemia that results from **parathyroid dysfunction**, not as the cause itself. - Insufficient supplementation would worsen pre-existing hypocalcemia but does not explain the initial onset without underlying **parathyroid injury or dysfunction**. *Secondary hypothyroidism* - **Secondary hypothyroidism** results from **pituitary dysfunction** leading to insufficient TSH production, and does not directly cause hypocalcemia. - The patient's initial presentation with a thyroid nodule and elevated calcitonin is not indicative of a pituitary disorder, nor is hypocalcemia a direct consequence.

Question 300: A patient with a thyroid nodule undergoes fine-needle aspiration, which reveals a follicular neoplasm. What is the next step?

A. Lobectomy (Correct Answer)
B. Total thyroidectomy
C. Radioactive iodine therapy
D. Observation

Explanation: ***Lobectomy*** - A **follicular neoplasm** on fine-needle aspiration (FNA) is an indeterminate finding, meaning it cannot definitively distinguish between a benign **follicular adenoma** and a malignant **follicular carcinoma**. - A **diagnostic lobectomy** allows for definitive histological examination of the entire nodule to determine malignancy, while preserving the other thyroid lobe. *Total thyroidectomy* - This is typically reserved for confirmed malignancies that are large, multifocal, or have evidence of extrathyroidal extension or lymph node involvement. - Performing a total thyroidectomy without definitive diagnosis carries the risk of unnecessary surgery and associated complications like **hypoparathyroidism** and **recurrent laryngeal nerve injury** if the nodule turns out to be benign. *Radioactive iodine therapy* - This is a treatment for **hyperthyroidism** or as an adjuvant therapy after surgery for **differentiated thyroid cancer** (papillary or follicular carcinoma) to ablate residual thyroid tissue or metastases. - It is not a diagnostic procedure and is not used as a primary treatment for an undiagnosed thyroid nodule or follicular neoplasm. *Observation* - Observation is generally reserved for benign thyroid nodules (e.g., colloid nodules) or very small, low-risk papillary microcarcinomas in selected patients. - A follicular neoplasm has an inherent risk of malignancy (15-30%), making observation an inappropriate and potentially dangerous course of action.

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

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free