Endocrine Surgery Practice Questions

Q: In the evaluation of a 64-year-old woman with fluctuating neurological signs, including ptosis, eleventh and twelfth cranial nerve palsy, and generalized extremity weakness. Edrophonium (Tensilon) given intravenously results in clinical improvement. A computed tomography (CT) scan shows a lesion in the anterior mediastinum, and a biopsy confirms the presence of a thymoma. She should undergo which of the following?

Thymectomy. ***Thymectomy*** - The combination of **fluctuating neurological signs** (ptosis, cranial nerve palsies, generalized weakness) improving with **edrophonium** strongly suggests **myasthenia gravis**. - **Thymomas** are present in 10-15% of myasthenia gravis patients; **thymectomy** is indicated for nearly all patients with thymoma, regardless of tumor stage, as it can lead to improvement or remission of myasthenic symptoms and is crucial for tumor removal. *High-dose steroid therapy* - While **steroids** can be used to treat symptoms of **myasthenia gravis**, they are typically used for symptom control or as an adjunct to surgery, not as the primary curative treatment, especially in the presence of a **thymoma**. - Steroids do not address the underlying **thymoma**, which needs surgical removal. *Radiation therapy for the anterior mediastinum* - **Radiation therapy** for a **thymoma** is usually considered as an adjunctive treatment after surgery, for unresectable tumors, or in cases of recurrence. - It is not the primary treatment when surgery (thymectomy) is a viable option for tumor removal. *Calcium supplementation* - **Calcium supplementation** is not relevant to the treatment of **myasthenia gravis** or **thymoma**. - This intervention would be appropriate for conditions like hypocalcemia, which is not indicated by the patient's symptoms.

Q: A patient has hypocalcaemia, which was the result of a surgical complication. Which operation could it possibly have been?

Thyroidectomy. ***Thyroidectomy*** - **Hypocalcemia** is a common complication of thyroidectomy due to **unintentional removal** or **damage to the parathyroid glands** during surgery. - The parathyroid glands regulate calcium levels, and their impairment leads to decreased **parathyroid hormone (PTH)** production, resulting in low serum calcium. *Nephrectomy* - **Nephrectomy** involves the surgical removal of a kidney and is not directly associated with immediate postoperative hypocalcemia as a typical complication. - While chronic kidney disease can affect calcium metabolism, the acute removal of a kidney does not primarily cause **hypocalcemia**. *Vocal cord tumor biopsy* - A **vocal cord tumor biopsy** is a procedure typically performed through the mouth or a small incision in the neck, focusing on the larynx. - This procedure usually does not involve structures critical for calcium regulation, such as the parathyroid glands, and therefore, **hypocalcemia** is not an expected complication. *Gastrectomy* - **Gastrectomy** is the surgical removal of part or all of the stomach, most commonly performed for stomach cancer or severe ulcers. - While long-term issues like **malabsorption** of calcium and vitamin D can occur after gastrectomy, acute postoperative **hypocalcemia** due to surgical damage to calcium-regulating glands is not typical.

Q: Which of the following medications is not typically used in the preoperative management of thyrotoxicosis?

Nifedipine. ***Nifedipine*** - **Nifedipine** is a **calcium channel blocker** used for hypertension and angina, but it has no role in the direct management of **thyrotoxicosis** or stabilization for thyroid surgery. - Its primary mechanism of action involves **vasodilation**, which is not beneficial for reducing thyroid hormone synthesis or release. *Propranolol* - **Propranolol** is a **beta-blocker** that helps control the **symptomatic effects** of thyrotoxicosis, such as tachycardia, tremors, and anxiety. - It also *inhibits the peripheral conversion of T4 to T3*, making it a crucial component of preoperative management. *Carbimazole* - **Carbimazole** is an **antithyroid drug** that *inhibits the synthesis of thyroid hormones* by blocking the enzyme **thyroid peroxidase**. - It is used to achieve a **euthyroid state** before surgery, reducing the risk of complications such **as thyroid storm**. *Lugol's Iodine* - **Lugol's Iodine** **acutely blocks the release of pre-formed thyroid hormones** from the thyroid gland and **reduces the vascularity of the gland**, making surgery safer. - It is typically administered **10-14 days before surgery** after antithyroid medications have been initiated.

Q: A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?

3%. ***3%*** - **Purely cystic thyroid nodules** (as described in this case with "isolated cystic swelling") have a **very low risk of malignancy**, typically **2-3%** or less. - According to **ATA guidelines** and **TIRADS classification**, purely cystic nodules are considered **low suspicion** lesions. - The cystic nature suggests a **benign process** such as a degenerated adenoma, colloid cyst, or simple cyst. - **Fine needle aspiration (FNA)** may still be considered if the nodule is >2 cm or has any suspicious solid components, but is often not required for purely cystic lesions. *48%* - This percentage is **significantly higher** than the actual malignancy risk for a purely cystic thyroid swelling. - Such a **high risk** would typically be associated with **solid nodules** exhibiting highly suspicious ultrasound features such as: - Microcalcifications - Irregular or spiculated margins - Taller-than-wide shape - Marked hypoechogenicity - Extrathyroidal extension *24%* - This percentage represents a **moderate to high risk** of malignancy, which is **not characteristic** of an isolated purely cystic thyroid swelling. - A risk in this range might be seen with: - **Mixed solid-cystic nodules** with predominantly solid components - Solid nodules with **intermediate suspicious features** on ultrasound *12%* - While lower than 24% or 48%, 12% is still **considerably higher** than the generally accepted malignancy risk for purely cystic thyroid nodules. - This risk level could be plausible for: - **Predominantly cystic nodules** with some eccentric solid components - Solid nodules with **mildly suspicious** features on ultrasound

Question 1

In the evaluation of a 64-year-old woman with fluctuating neurological signs, including ptosis, eleventh and twelfth cranial nerve palsy, and generalized extremity weakness. Edrophonium (Tensilon) given intravenously results in clinical improvement. A computed tomography (CT) scan shows a lesion in the anterior mediastinum, and a biopsy confirms the presence of a thymoma. She should undergo which of the following?

Accepted Answer

Thymectomy

Answer

High-dose steroid therapy

Answer

Radiation therapy for the anterior mediastinum

Answer

Calcium supplementation

Question 2

A patient has hypocalcaemia, which was the result of a surgical complication. Which operation could it possibly have been?

Accepted Answer

Thyroidectomy

Answer

Nephrectomy

Answer

Vocal cord tumor biopsy

Answer

Gastrectomy

Question 3

Which of the following medications is not typically used in the preoperative management of thyrotoxicosis?

Accepted Answer

Nifedipine

Answer

Propranolol

Answer

Carbimazole

Answer

Lugol's Iodine

Question 4

A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?

Accepted Answer

3%

Answer

48%

Answer

12%

Answer

24%

Endocrine Surgery — MCQs

Endocrine Surgery — MCQs

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