Endocrine Surgery Practice Questions

Q: A 40-year-old female presents with a slow-growing, painless mass. She is recently diagnosed with thyroid cancer. Which is the most common subtype of thyroid cancer?

Papillary carcinoma. **Explanation:** **Papillary Thyroid Carcinoma (PTC)** is the most common subtype of thyroid cancer, accounting for approximately **80–85%** of all thyroid malignancies. It typically presents as a slow-growing, painless, "cold" nodule in females (3rd–5th decades). The diagnosis is primarily made via Fine Needle Aspiration Cytology (FNAC), which reveals characteristic nuclear features like **Orphan Annie eye nuclei** (cleared-out chromatin), **Psammoma bodies** (laminated calcifications), and nuclear grooves. **Analysis of Incorrect Options:** * **Follicular Carcinoma (Option C):** The second most common (10–15%). Unlike PTC, it spreads **hematogenously** (to bone/lungs) and cannot be diagnosed by FNAC alone, as it requires histological evidence of capsular or vascular invasion. * **Medullary Carcinoma (Option A):** Accounts for ~5%. It arises from **Parafollicular C-cells** and secretes calcitonin. It is associated with MEN 2A and 2B syndromes. * **Anaplastic Carcinoma (Option D):** Rare (<2%) but highly aggressive. It typically presents in elderly patients as a rapidly enlarging mass with a very poor prognosis. **High-Yield Clinical Pearls for NEET-PG:** * **Route of Spread:** PTC spreads primarily via **lymphatics** (Level VI nodes first). * **Risk Factor:** Prior exposure to **ionizing radiation** is the most significant risk factor for PTC. * **Prognosis:** PTC has an excellent 10-year survival rate (>90%). * **Molecular Marker:** **BRAF V600E** mutation is the most common genetic alteration in PTC.

Q: In the early postoperative period after excision of a pheochromocytoma, which complication is least likely?

Hypertension. **Explanation:** The primary hemodynamic challenge in the early postoperative period following pheochromocytoma excision is **hypotension**, not hypertension. Once the tumor is removed, the sudden withdrawal of high levels of circulating catecholamines, combined with a chronically constricted vascular bed and potential down-regulation of adrenoceptors, leads to profound vasodilation and a drop in blood pressure. Therefore, **Hypertension (Option B)** is the least likely complication. * **Infection (Option A):** Like any major abdominal or retroperitoneal surgery, surgical site infections (SSI) are a standard postoperative risk. * **Atelectasis (Option C):** This is the most common respiratory complication in the first 24–48 hours post-surgery, especially in procedures involving upper abdominal incisions or prolonged anesthesia. * **Bleeding (Option D):** The adrenal glands are highly vascular, and the proximity to major vessels (IVC on the right, renal vein on the left) makes postoperative hemorrhage a recognized risk. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Pheochromocytoma:** Episodic headache, sweating, and tachycardia. * **Pre-operative Preparation:** Always start **Alpha-blockers first** (e.g., Phenoxybenzamine) for 10–14 days, followed by Beta-blockers. Starting Beta-blockers first can cause an unopposed alpha-agonistic effect, leading to a hypertensive crisis. * **Post-op Hypoglycemia:** Removal of the tumor eliminates catecholamine-induced inhibition of insulin; patients must be monitored for rebound hyperinsulinemia and hypoglycemia. * **Fluid Management:** Aggressive volume expansion is required post-excision to counteract the expanded vascular space.

Q: Regarding follicular carcinoma of the thyroid, which of the following statements is true?

It spreads primarily through the hematogenous route.. **Explanation:** **1. Why Option C is Correct:** Follicular Thyroid Carcinoma (FTC) is characterized by its tendency for **hematogenous (blood-borne) spread**. Unlike Papillary Thyroid Carcinoma (PTC), which spreads via lymphatics, FTC cells invade blood vessels. This leads to distant metastases, most commonly to the **lungs and bones** (often presenting as osteolytic, pulsating bone lesions). **2. Why the Other Options are Incorrect:** * **Option A:** **Papillary Carcinoma** is the most common type of thyroid cancer (approx. 80-85%), whereas Follicular Carcinoma is the second most common (approx. 10-15%). * **Option B:** FTC is **not** readily diagnosed by Fine Needle Aspiration Cytology (FNAC). FNAC cannot distinguish between a benign follicular adenoma and a follicular carcinoma because the diagnosis of malignancy depends on identifying **capsular or vascular invasion**, which requires histological examination of the entire nodule. * **Option D:** FTC is typically a **solitary lesion**. Multifocality is a hallmark feature of Papillary Thyroid Carcinoma, not Follicular Carcinoma. **3. NEET-PG High-Yield Pearls:** * **Hürthle Cell Carcinoma:** A variant of FTC; it is less likely to take up iodine and has a higher rate of lymph node metastasis compared to typical FTC. * **Risk Factor:** FTC is more common in areas of **iodine deficiency** (endemic goiter belts). * **Tumor Marker:** **Thyroglobulin** is used to monitor for recurrence post-total thyroidectomy. * **Management:** Total thyroidectomy followed by Radioactive Iodine (RAI) ablation is the standard for tumors >1 cm or those with vascular invasion.

Q: A 6-year-old child complains of difficulty in swallowing and on examination, there is a sublingual swelling, which is suspected to be lingual thyroid. What is the first step in the management of this child?

Thyroid scan. **Explanation:** The correct answer is **Thyroid scan (Option B)**. A **lingual thyroid** is the most common form of ectopic thyroid tissue, resulting from the failure of the thyroid gland to descend from the foramen cecum to its normal pre-tracheal position during embryogenesis. In approximately **70-75% of cases**, the lingual thyroid is the **only functioning thyroid tissue** present in the body. Before any surgical intervention or biopsy, it is mandatory to perform a thyroid scan (using Technetium-99m or Iodine-123) to: 1. Confirm the presence of ectopic thyroid tissue. 2. Determine if there is any normally located thyroid tissue in the neck. Removing a lingual thyroid without checking for a normal gland would render the patient permanently hypothyroid. **Why other options are incorrect:** * **Options A & C:** Tracheostomy and intubation are emergency measures for acute airway obstruction. While a large lingual thyroid can cause dysphagia or mild respiratory distress, it rarely presents as a sudden airway emergency requiring immediate invasive procedures unless there is acute hemorrhage or severe stridor. * **Option D:** Surgery is not the immediate first step. Many patients are managed conservatively with suppressive levothyroxine therapy to shrink the gland. Surgery is reserved for severe obstruction, bleeding, or malignancy. **Clinical Pearls for NEET-PG:** * **Most common site of ectopic thyroid:** Base of the tongue (Lingual thyroid). * **Gender Predilection:** More common in females (4:1 ratio). * **Clinical Presentation:** Often asymptomatic until puberty or pregnancy (due to increased physiological demand for T4). * **Diagnosis:** Thyroid scan is the gold standard; Ultrasound of the neck is used to check for the presence of a normal gland.

Q: Which vessels supply a secondary retrosternal goitre?

Thyroid vessels. **Explanation:** The classification and surgical management of retrosternal goitres depend heavily on their embryological origin and blood supply. **1. Why Thyroid Vessels are Correct:** A **secondary retrosternal goitre** (the most common type, accounting for >95% of cases) originates in the neck from the thyroid gland. Due to negative intrathoracic pressure, gravity, and the constraints of the pretracheal fascia, the enlarging thyroid gland is "pushed" or "sucked" down into the superior mediastinum. Because it originates in the neck, it **retains its original blood supply** from the **superior and inferior thyroid arteries**. This is a critical surgical fact: most secondary goitres can be delivered through a standard cervical incision because their vascular pedicle is accessible from the neck. **2. Why Other Options are Incorrect:** * **Mediastinal vessels:** These supply **primary** retrosternal goitres (ectopic thyroid tissue), which are rare (<1%) and located entirely in the chest without a connection to the cervical thyroid. * **Arch of aorta & Bronchial vessels:** These do not provide the primary blood supply to thyroid tissue. While the *Thyroidea ima* artery (an anatomical variant) can arise from the aortic arch or brachiocephalic trunk, it is not the standard supply for a secondary goitre. **Clinical Pearls for NEET-PG:** * **Primary vs. Secondary:** Primary goitres are ectopic and supplied by intrathoracic vessels; Secondary goitres are migrations and supplied by cervical vessels. * **Surgical Approach:** Most secondary goitres can be removed via a **cervical incision**. A sternotomy is rarely required (<5%) unless the goitre is primary, malignant, or larger than the thoracic inlet. * **Definition:** A goitre is typically defined as retrosternal if more than 50% of its volume lies below the plane of the thoracic inlet.

Q: Which of the following conditions is associated with laryngeal nerve paralysis?

Anaplastic thyroid cancer. **Explanation:** The correct answer is **Anaplastic thyroid cancer**. **1. Why Anaplastic Thyroid Cancer is correct:** The Recurrent Laryngeal Nerve (RLN) runs in the tracheoesophageal groove, in close proximity to the thyroid gland. In cases of **malignant** thyroid tumors, especially aggressive types like Anaplastic carcinoma, the tumor frequently breaches the thyroid capsule and **infiltrates** surrounding structures. Paralysis of the vocal cords occurs due to direct neoplastic invasion or compression of the RLN. In clinical practice, a thyroid mass associated with hoarseness of voice (vocal cord palsy) is a hallmark sign of malignancy. **2. Why the other options are incorrect:** * **Multinodular Goitre (MNG):** This is a benign condition. While the gland can become very large (retrosternal goitre), it rarely causes nerve paralysis because it tends to displace the nerve rather than invade it. * **Graves' Disease:** This is an autoimmune hyperthyroid state characterized by diffuse hyperplasia. It does not involve invasive growth or nerve destruction. * **Riedel’s Thyroiditis:** Although this involves dense fibrosis that can mimic malignancy by "fixing" the thyroid to local structures, RLN paralysis is extremely rare compared to the invasive nature of Anaplastic cancer. **3. NEET-PG High-Yield Pearls:** * **Most common cause of unilateral RLN palsy:** Thyroid surgery (iatrogenic trauma). * **Most common thyroid malignancy causing RLN palsy:** Anaplastic carcinoma (due to its rapid, aggressive local invasion). * **Semon’s Law:** In progressive lesions of the RLN, the abductor fibers (Posterior Cricoarytenoid) are more susceptible and paralyzed before the adductor fibers. * **Position of Cord:** In complete RLN paralysis, the vocal cord usually assumes a **paramedian position**.

Question 1

A 40-year-old female presents with a slow-growing, painless mass. She is recently diagnosed with thyroid cancer. Which is the most common subtype of thyroid cancer?

Accepted Answer

Papillary carcinoma

Answer

Medullary carcinoma

Answer

Follicular carcinoma

Answer

Anaplastic carcinoma

Question 2

Which of the following complications will NOT lead to respiratory distress after thyroid surgery?

Accepted Answer

Hypocalcemia

Answer

Seroma at the surgical site

Answer

Recurrent laryngeal nerve injury

Answer

Hematoma at the surgical site

Question 3

A 40-year-old female who underwent subtotal thyroidectomy developed respiratory distress 8 hours after the operation. The skin sutures were opened in the ward but the distress persisted. What is the next likely step in management?

Accepted Answer

Open the layers of the wound in the ward.

Answer

Immediately shift the patient to the operation theatre.

Answer

Patient should be intubated in the ward.

Answer

External pressure should be applied over the neck to stop bleeding.

Question 4

In the early postoperative period after excision of a pheochromocytoma, which complication is least likely?

Accepted Answer

Hypertension

Answer

Infection

Answer

Atelectasis

Answer

Bleeding

Question 5

Regarding follicular carcinoma of the thyroid, which of the following statements is true?

Accepted Answer

It spreads primarily through the hematogenous route.

Answer

It is the most common type of thyroid cancer.

Answer

It is readily diagnosed.

Answer

It is commonly multifocal.

Question 6

All of the following are associated with Thyroid storm, EXCEPT:

Accepted Answer

Surgery for thyroiditis

Answer

Surgery for thyrotoxicosis

Answer

Stressful illness in thyrotoxicosis

Answer

I-131 therapy for thyrotoxicosis

Question 7

A 6-year-old child complains of difficulty in swallowing and on examination, there is a sublingual swelling, which is suspected to be lingual thyroid. What is the first step in the management of this child?

Accepted Answer

Thyroid scan

Answer

Tracheostomy and airway maintenance

Answer

Intubation

Answer

Explain to the child's parents that he may require immediate surgery

Question 8

What is the preferred approach for a retrosternal goitre?

Accepted Answer

Transcervical approach

Answer

Transthoracic approach at the 2nd intercostal space

Answer

Transthoracic approach at the 4th intercostal space

Answer

Transsternal approach to the anterior mediastinum

Question 9

Which vessels supply a secondary retrosternal goitre?

Accepted Answer

Thyroid vessels

Answer

Mediastinal vessels

Answer

Arch of aorta

Answer

Bronchial vessels

Question 10

Which of the following conditions is associated with laryngeal nerve paralysis?

Accepted Answer

Anaplastic thyroid cancer

Answer

Multinodular goitre

Answer

Graves' disease

Answer

Riedel's thyroiditis

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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