1) ENDOCRINE SYSTEM Flashcards
Which of the following features of Graves disease does not improve with Antithyroid therapy?
a) Tremor
b) Anxiety
c) Graves Dermopathy
d) GIT Disturbances
e) Exophthalmos
E) Exophthalmos
Exophthalmos is the only symptom that is resistant to ATDs.
o RAI is contraindicated in patient’s with Exophthalmos.
o Recommended therapy:
Steroids —- ATDs —- Surgery.
A 40-year-old female presents with a large thyroid nodule. Workup & subsequent resection demonstrate a 4 cm papillary thyroid CA with positive lymph nodes and local extension but no evidence of Distant disease. What stage is her cancer?
a) Stage 1
b) Stage 2
c) Stage 3
d) Stage 4
e) Stage 5
A) Stage 1
Age is the most important factor in thyroid cancer. According to 8th edition of AJCC, the patients with age <55 can only be classified as Stage 1 or Stage 2:
Stage 1: No distant Metastasis
Stage 2: Distant Metastasis.
Thus, lymph node status & size of the tumor are not taken into consideration.
A 46-year-old female with a 3 cm palpable right sided thyroid nodule has a FNA performed, which is reported as Non-diagnostic. What is the next best step?
a) Repeat FNA
b) Core Needle Biopsy
c) Right thyroid Lobectomy
d) Total Thyroidectomy
e) Ultrasound in 6 Months
A) Repeat FNA.
A 51-year-old male with a 2 cm palpable right sided thyroid nodule has a FNA performed, which is reported as Follicular Lesion of Undetermined Significance [FLUS]. Which of the following is true about this condition?
a) Repeat FNA is not recommended.
b) Molecular testing does not influence management.
c) Right Thyroid Lobectomy is an acceptable option.
d) Total Thyroidectomy is the Next Best Step.
e) Ultrasound follow-up in 6 months in the best option.
c) Right Thyroid Lobectomy is an acceptable option.
The current recommendation is to perform A Repeat FNA.
The thyroid gland is derived from which embryologic structure?
a) 1st Pharyngeal arch
b) 2nd Pharyngeal pouch
c) 3rd Pharyngeal arch
d) 4th Pharyngeal arch
e) 4th Pharyngeal pouch
a) 1st Pharyngeal arch
Thyroid gland = 1st & 2nd Pharyngeal Arches.
Superior Parathyroid Glands = 4th Pharyngeal Pouch
Inferior Parathyroid Glands = 3rd Pharyngeal Pouch
[ P = Parathyroid = Pouch]
Which of the following cancers most commonly metastasises to the thyroid?
a) Parathyroid gland
b) Kidney
c) Lung
d) Breast
e) Esophageal CA
B) Kidney
Renal Cell Carcinoma is the most commonly metastasised tumor to the thyroid gland.
Parathyroid gland doesn’t metastasise to thyroid gland.
Which of the following is true regarding Hurthle Cell Carcinoma?
a) It contains an abundance of oncocytic or oxyphilic cells.
b) Lymph node metastasis is exceedingly rare.
c) Diagnosis of malignancy is usually made by FNA.
d) Residual disease is effectively treated with Iodine 131.
e) Histologically they demonstrate Orphan Annie Cells.
a) It contains an abundance of oncocytic or oxyphilic cells.
Following are the important points regarding Hurthle Cell Carcinoma:
1. Subtype of Follicular Carcinoma & accounts for <10% of thyroid malignancies.
2. Like Follicular Carcinoma, the presence of malignancy is demostrated by Capsular or Vascular Invasion.
3. Like Follicular Carcinoma, FNA doesn’t establish the diagnosis.
4. Residual disease is not effectively treated with RAI because Hurthle Cell CA do not take up radioactive iodine.
5. Hurtle Cell CA is different from Follicular CA as they are highly aggressive and more likely to spread to lymph nodes as compaered to follicular CA.
Which of the following is true regarding follicular thyroid cancer?
a) It is the most common thyroid malignancy.
b) Commonly spreads via a hematogenous route.
c) Prophylactic nodal dissection is recommended.
d) It is best managed by Hemithyroidectomy.
e) Multicentricity is common.
b) Commonly spreads via a hematogenous route
Following are the important points regarding follicular CA:
1. Multicentricity is uncommon.
2. The presence of malignancy is demostrated by Capsular or Vascular Invasion.
3. If FNA demostrates Follicular Neoplasm, NBS Lobectomy. If histology confirms the diagnosis of Malignancy, then the patient should undergo Total Thyroidectomy.
4. Lymph node dissection is not recommended as the follicular carcinoma doesn’t have lymph nodal spread.
The most common type of thyroid cancer in children is?
a) Papillary
b) Follicular
c) Medullary
d) Hurthle Cell
e) Anaplastic
a) Papillary
Papillary CA is the most common thyroid malignancy in both children & adults.
Calcified clumps of cells on histology are consistent with?
a) Papillary
b) Follicular
c) Medullary
d) Hurthle Cell
e) Anaplastic
a) Papillary
Psammoma bodies = Calcified clumps of cells
A 65-year-old woman with a history of Hashimoto thyroiditis presents with fever, dysphagia and a painless thyroid mass that has enlarged over a short period of time. This most likely represents?
a) Lymphoma
b) Follicular CA
c) Anaplastic CA
d) Acute Suppurative Thyroiditis
e) Medullary Thyroid CA
A) Lymphoma
- Hashimoto thyroiditis is the most common cause of Hypothyroidism.
- Hashimoto thyroiditis is associated with Lymphoma.
- Patient additionally can develop fever, dysphagia and hoarseness of voice.
- In a patient with Hashimoto thyroiditis, Lymphoma should be suspected in the setting of a rapidly enlarging thyroid mass.
After total thyroidectomy & postoperative iodine ablation for a 5 cm follicular thyroid cancer, the best test to monitor for recurrent disease is?
a) Serum TSH
b) Serum Calcitonin
c) Serum Thyroglobulin
d) 131 Iodine Scan
e) U/S Neck
C) Serum Thyroglobulin levels are the most useful modality to monitor patients for recurrence of differentiated thyroid cancer [Papillary & Follicular] after total thyroidectomy & RAI.
Malignancy within a thyroglossal duct cyst is typically?
a) Follicular CA
b) Papillary CA
c) Squamous CA
d) Anaplastic CA
e) Hurthle Cell CA
B) Papillary CA
Papillary CA is associated with cyst formation.
After a total thyroidectomy, the right vocal cord is noted to be fixed in a paramedian position. This most likely represents:
A. Injury to the recurrent laryngeal nerve (RLN)
B. Injury to the external branch of the superior laryngeal nerve C. Injury to the internal branch of the superior laryngeal nerve D. Trauma from endotracheal intubation
E. Compression from hematoma
A. Injury to the recurrent laryngeal nerve (RLN)
- The RLN innervates the intrinsic muscles of the larynx, except the cricothyroid muscles, which are innervated by the external branch.
- Injury to one RLN leads to paralysis of the ipsilateral vocal cord. The cord becomes fixed in either the paramedian position or the abducted position. If the cord becomes fixed in the paramedian position, the patient will have a weak voice, whereas if it becomes fixed in the abducted position, the patient will have a hoarse voice and an ineffective cough.
- If both RLNs are injured, an airway obstruction may develop acutely in the patient. of the superior laryngeal nerve.
During thyroidectomy the superior thyroid arteries were ligated a centimeter away from the thyroid capsule as opposed to immediately adjacent to it. This technical error would most likely result in which of the following complications?
A. Voice fatigue
B. Hoarseness
C. Loss of airway
D. Aspiration
E. Ineffective cough
A. Voice fatigue
The external branch of the superior laryngeal nerve lies on the inferior pharyngeal constrictor muscle and descends alongside the superior thyroid artery before innervating the cricothyroid muscle. Injury to the external superior laryngeal nerve results in an inability to tense the ipsilateral vocal cord and difficulty hitting high notes, projecting the voice, and voice fatigue during a prolonged speech.
A 45-year-old woman with a history of a goiter presents to the emergency department with a high fever, heart rate of 130 beats per minute, tremors, sweating, and exophthalmos. Which of the following can exacerbate symptoms?
A. Aspirin
B. Propylthiouracil
C. Beta-blocker
D. Methimazole
E. Steroids
A. Aspirin
Aspirin is contraindicated in thyroid storm because it is
thought to decrease protein binding of thyroid hormones. Thus, it may increase the levels of unbound T3 and T4.
Which of the following is true regarding substernal goiter?
A. Surgical resection should be reserved for patients with tracheal deviation.
B. Most are primary mediastinal goiters with a blood supply arising from intrathoracic vessels.
C. Most can be resected by a cervical incision.
D. Most are highly responsive to prolonged thyroid suppression.
E. Because of the risk of tracheomalacia, most patients should have a prophylactic tracheostomy at the time of resection.
C. Most can be resected by a cervical incision.
Substernal goiter is divided into primary and secondary forms. Primary forms, defined as ones that originate in the mediastinum with blood supply from intrathoracic vessels, are very rare. Most substernal goiters are extensions from cervical goiters. Most surgeons recommend resection for the mere presence of a substernal goiter because most are symptomatic, and those that are not can cause progressive compression of the trachea.
The majority can be successfully removed with a cervical collar incision. Sternotomy is very rarely needed nor is tracheostomy because most can be intubated, even in the face of tracheal compression, with a pediatric endotracheal tube
The most accurate test for hyperthyroidism is:
A. Free thyroxine (T4)
B. Total T4
C. Total triiodothyronine (T3)
D. Thyroid-stimulating hormone (TSH)
E. Thyroid scan
D. TSH is the most accurate test in hyperthyroidism
Which of the following is true regarding the blood supply to the thyroid/parathyroid glands?
A. The parathyroid glands are usually supplied by the superior thyroid arteries.
B. The inferior thyroid artery is the first branch of the external carotid artery.
C. The RLNs are at risk of injury during ligation of the superior thyroid arteries.
D. The external branch of the superior laryngeal nerve is at risk of injury when the inferior laryngeal arteries are ligated
E. The thyroidea ima artery usually arises from the aorta.
E. The thyroidea ima artery usually arises from the aorta.
- The thyroid gland is supplied by paired superior thyroid arteries from the external carotid arteries and the inferior thyroid arteries from the thyrocervical trunk. The superior thyroid artery is the first branch of the external carotid artery.
- During thyroidectomy, care must be taken when ligating the superior thyroid arteries to avoid injury to the external branch of the superior laryngeal nerve.
- When ligating the inferior thyroid arteries, care must be taken to avoid injury to the RLNs.
- The inferior thyroid arteries usually supply the parathyroid glands (A). Ligation of the main trunk of the inferior thyroid arteries during total thyroidectomy can lead to parathyroid gland ischemia.
Which of the following is true regarding the laryngeal nerves?
A. The external branch of the superior laryngeal nerve provides sensation to the larynx.
B. Bilateral injury to the superior laryngeal nerves often results in acute airway obstruction.
C. The right RLN separates from the vagus after crossing the subclavian artery.
D. The recurrent laryngeal nerve is both motor and sensory to the larynx.
E. The RLNs provide motor function to the cricothyroid.
C. The right RLN separates from the vagus after crossing the subclavian artery.
A non-RLN:
A. Does not exist
B. Is more common on the left
C. Can occur in conjunction with a recurrent nerve on the right
D. Loops around the aorta on the right side
E. Is less prone to injury during surgery than a recurrent nerve
C. Can occur in conjunction with a recurrent nerve on the right.
Following are the important points regarding non-RLN:
1. A non-RLN is rare and occurs much more commonly on the right.
2. It branches off the vagus nerve in the neck and heads directly to the larynx, as opposed to arising from the vagus after passing the subclavian artery.
3. The anomalous location, as opposed to its normal position in the tracheoesophageal groove, makes it more prone to injury.
4. On the right, a patient can have both a nonrecurrent nerve and a recurrent nerve.
Lateral aberrant thyroid in most instances represents:
A. Metastatic papillary carcinoma
B. Metastatic follicular carcinoma
C. Metastatic Hürthle cell carcinoma
D. A congenital lesion related to thyroid descent E. An extension of a thyroglossal duct cyst
A. Metastatic papillary carcinoma
Lateral aberrant thyroid is a term used to denote what appears to be ectopic thyroid tissue found within the neck. In most instances, it actually represents metastatic thyroid cancer within a lymph node, most often of the papillary type.
A 45-year-old woman presents with a 1.5-cm right thyroid nodule. FNA findings are consistent with papillary carcinoma. Her history is significant for radiation therapy for lymphoma as a child. Optimal management of this patient would consist of:
A. Right hemithyroidectomy
B. Right hemithyroidectomy plus central lymph node dissection
C. Total thyroidectomy
D. Total thyroidectomy with postoperative 131I
E. Total thyroidectomy plus right modified radical neck dissection
C. Total thyroidectomy
TOC for Papillary CA is Total Thyroidectomy.
Following are the indications of RAI:
1. Tumors larger than 4 cm
2. Gross extrathyroidal extension of the tumor regardless of size.
3. Lymph node metastases
4. For high-risk features including tall-cell or columnar-cell variant.
A 35-year-old woman with a history of previous right thyroidectomy for a benign thyroid nodule now undergoes completion thyroidectomy for a suspicious thyroid mass. Several hours postoperatively, she develops progressive swelling under the incision, stridor, and difficulty breathing. Orotracheal intubation is successful. Which of the following is the most appropriate next step?
a. Fiberoptic laryngoscopy to rule out bilateral vocal cord paralysis
b. Administration of intravenous calcium
c. Administration of broad-spectrum antibiotics and debridement of the wound
d. Wound exploration
e. Administration of high-dose steroids and antihistamines
d. Wound exploration
The clinical presentation is consistent with a wound hematoma and necessitates exploration of the wound, drainage of the hematoma, and identification and control of any bleeding vessels.
If airway compromise is impending, the wound should be opened at the bedside and not delayed until endotracheal intubation or transport to the operating room has been obtained.
A 55-year-old woman presents with a slow-growing painless mass in her neck. A complete neck ultrasound demonstrates a 1-cm nodule in the right thyroid without masses in the contralateral lobe or lymph node metas- tasis in the central and lateral neck compartments. A fine-needle aspiration of the nodule shows a well-differentiated papillary carcinoma. With regards to this patient, which of the following is associated with a poor prognosis?
a. Age
b. Sex
c. Grade of tumor
d. Size of tumor
e. Lymph node status
a. Age is a very important prognostic indicator in well-differentiated thyroid cancer (papillary and follicular). Age >55 years is associated with a worse prognosis.
A 55-year-old woman presents with a 6-cm right thyroid mass and palpable cervical lymphadenopathy. Fine-needle aspiration (FNA) of one of the lymph nodes demonstrates the presence of thyroid tissue. Which of the following best describes the management of this thyroid disorder?
a. Screening for pancreatic endocrine neoplasms and hypercalcemia
b. Total thyroidectomy with modified radical neck dissection
c. Total thyroidectomy with frozen section intraoperatively, with modified radical
neck dissection reserved for patients with extra-capsular invasion
d. Right thyroid lobectomy followed by iodine 131 (131I) therapy
e. Right thyroid lobectomy
b. Total thyroidectomy with modified radical neck dissection.
Treatment of high-risk papillary carcinomas consists of total thyroidectomy. If patients have lymph node metasta- ses in the lateral neck, concomitant modified radical neck dissection should be performed with total thyroidectomy.
A 29-year-old woman with a history of difficulty becoming pregnant presents to her primary care physician and is diagnosed with Graves disease on iodine uptake scan; her thyrotropin (TSH) level is markedly suppressed and her free thyroxine (T4) level is elevated. She desires to conceive as soon as possible and elects to undergo thyroidectomy. After she is rendered euthyroid with medications preoperatively, which of the following manage- ment strategies should also be employed to reduce the risk of developing thyroid storm in the operating room?
a. Drops of Lugol iodine solution daily beginning 10 days preoperatively
b. Preoperative treatment with phenoxybenzamine for 3 weeks
c. Preoperative treatment with propranolol for 1 week
d. Twenty-four hours of corticosteroids preoperatively
e. No other preoperative medication is required
a. Drops of Lugol iodine solution daily beginning 10 days preoperatively.
Drops of Lugol iodide solution daily beginning 10 days preoperatively should be prescribed to decrease the likeli- hood of postoperative thyroid storm, a manifestation of severe thy- rotoxicosis. Lugol helps to decrease the vascularity of the thyroid itself. Propylthiouracil or methimazole can also be used preoperatively but are contraindicated in pregnant women. In addition, radioactive iodine cannot be used during pregnancy. If thyroid storm occurs, treatment is β-blockade, eg, propranolol.
A 58-year-old man presents with tachycardia, fever, confusion, and vomiting. Workup reveals markedly elevated (triiodothyronine) T3 and (thyroxine) T4 levels. He is diagnosed as having a thyroid storm. Which of the following is the most appropriate next step in the management of this patient?
a. Emergent subtotal thyroidectomy
b. Emergent total thyroidectomy
c. Emergent hemodialysis
d. Administration of fluid, antithyroid drugs, b-blockers, iodine solution, and steroids
e. Emergent radiation therapy to the neck
d. Administration of fluid, antithyroid drugs, b-blockers, iodine solution, and steroids.
A 36-year-old woman, 20 weeks pregnant, presents with a 1.5-cm right thyroid mass. FNA is consistent with a papillary neoplasm. The mass is cold on scan and solid on ultrasound. Which of the following methods of treatment is contraindicated in this patient?
a. Right thyroid lobectomy
b. Subtotalthyroidectomy
c. Total thyroidectomy
d. Total thyroidectomy with lymph node dissection
e. 131I radioactive ablation of the thyroid gland
e. Radioactive 131I is contraindicated in pregnancy and should be used with caution in women of childbearing age.
A 63-year-old woman notices lumps on both sides of her neck. A fine- needle aspirate is nondiagnostic, and she undergoes total thyroidectomy. Final pathology reveals a 4-cm Hürthle cell carcinoma. Which of the follow- ing is the most appropriate postsurgical management of this patient?
a. No further therapy is indicated
b. Chemotherapy
c. External beam radiotherapy
d. Radioiodine ablation
e. Chemotherapy, external beam radiotherapy, and radioiodine ablation
d. Radioiodine ablation
The treatment of Hürthle cell carcinoma follows the same principles as follicular carcinoma. Primary treatment is surgical followed by radioiodine ablation.
Hürthle cell cancer is a type of follicular cancer, but differs from follicular neoplasms in that it is more often multifocal and bilateral, and is more likely to spread to local nodes and distant sites.
A 51-year-old man presents with a 2-cm left thyroid nodule. Thyroid scan shows a cold lesion. FNA cytology demonstrates follicular cells. Which of the following is the most appropriate initial treatment of this patient?
a. External beam radiation to the neck
b. Multidrug chemotherapy
c. TSH suppression by thyroid hormone
d. Prophylactic neck dissection is indicated along with a total thyroidectomy
e. Thyroid lobectomy
e. Thyroid lobectomy
For lesions less than 4 cm in size, thyroid lobectomy is adequate because at least 80% of follicular lesions are adenomas.
For confirmed carcinomas or lesions greater than 4 cm in size, total thyroidectomy should be performed.
Following surgical resection of a large thyroid mass, a patient complains of persistent hoarse- ness and a weak voice. What is the most likely cause of these symptoms?
(A) Traumatic intubation
(B) Prolonged intubation
(C) Injury to the recurrent laryngeal nerve
(D) Injury to the superior laryngeal nerve
(E) Scar tissue extending to the vocal cords
(C) Injury to the recurrent laryngeal nerve
A 40-year-old woman presents with weight loss, palpitations, and exopthalmos. On phys- ical examination, the thyroid gland is diffusely enlarged. Blood tests reveal primary hyper- thyroidism. Which one of the following is not the treatment of hyperthyroidism?
(A) Methimazoli
(B) Lugols iodine
(C) I131
(D) Subtotal thyroidectomy
(E) Steroids
(E) Steroids
After undergoing a left thyroid operation, a 42-year-old opera singer notes no change in speech, but she has difficulty in singing high- pitched notes. Which nerve is most likely to be injured?
(A) Recurrent laryngeal
(B) Internal laryngeal
(C) External laryngeal
(C) External laryngeal
A 23-year-old Pacific Islander female is referred to you for evaluation for a left neck mass. She rarely receives any medical care. She has noticed the neck mass for the past 6 months.The lump is increasing in size with time. She states that otherwise, she feels normal. On physical exam, she has a palpable lump on her left thyroid gland as well as left neck lymphadenopathy. She is very thin with long limbs and round, firm lumps in her lips. You suspect she has multiple endocrine neoplasia (MEN) 2B syndrome. What potential abnormalities would you suspect and work up?
A. Papillary thyroid cancer
B. Pituitary adenoma
C. Pheochromocytoma
D. Parathyroid hyperplasia
C. Pheochromocytoma
What is the recommended initial surgical approach if the 1.1 cm lesion was non-diagnostic on initial and repeat FNA, and no lymphadenopathy is seen, and the patient desires a limited surgical procedure?
A. Repeat FNA again
B. Left thyroid lobectomy
C. Near-total thyroidectomy
D. Total thyroidectomy
B. Left thyroid lobectomy
Per the 2015 ATA guidelines, For patients with an isolated indeterminate solitary nodule, thyroid lobectomy is the recommended initial surgical approach.
Total thyroidectomy is recommended for indeterminate nodules which are:
a) Large (> 4 cm)
b) Show marked atypia present on biopsy
c) In patients with a family history of thyroid cancer
d) In patients with a history of radiation exposure.
What would be your treatment option if the 1.1 cm lesion showed suspicion of a papillary thyroid cancer on FNA and no lymphadenopathy on the thyroid ultrasound?
A. Follow-up with repeat ultrasound in 6 months
B. Left thyroid lobectomy
C. Left thyroidectomy with isthmusectomy
D. Total thyroidectomy
D. Total thyroidectomy
For Papillary CA, treatment of choice is Total Thyroidectomy
A 43-year-old female presented with a neck swelling. The ultrasound reveals a 0.4 cm circular, smooth, solid, intracapsular lesion. What would be your next step in management or this lesion?
A. Fine-needle aspiration (FNA)
B. Repeat lab work
C. Observation
D. Subtotal thyroidectomy
C. Observation
A 43-year-old female presented with a neck swelling. What would your next step be if the lesion were 1.1 cm on imaging and palpable?
A. FNA
B. Repeat lab work
C. Follow-up with repeat ultrasound in 6 months
D. Subtotal thyroidectomy
A. FNA
A 56-year-old man presents to clinic for evaluation of a small anterior right neck mass at the level of the thyroid. He has no significant past medical history and denies any history of smoking. The mass has been slowly enlarging over the last 2 years but is not painful. The patient is normotensive with a negative review of systems, and he denies any dyspnea, choking sensations, or hoarseness. What is the first diagnostic study that should be performed in the workup of this mass?
a. Ultrasonography of the thyroid
b. Serum thyroid-stimulating hormone (TSH) level
c. Fine-needle aspiration (FNA)
d. Computed tomography (CT) scan of the neck and chest
e. Thyroid scintigraphy
b. Serum thyroid-stimulating hormone (TSH) level
TSH level is the first study performed on an asymptomatic patient with a thyroid nodule >1 cm. Imaging is the next diagnostic step.
Following total thyroidectomy, a 50-year-old male presents for his 1-year follow-up visit. He is currently on daily levothyroxine therapy. The best method to monitor the adequacy of replacement therapy is:
a. Radioactive iodine (RAI) uptake
b. Thyroglobulin
c. Triiodothyronine resin uptake (RT3U)
d. Serum TSH level
e. Total thyroxine level (total T4)
d. Serum TSH level
Adequacy of thyroid hormone replacement is assessed 6 to 12 weeks after therapy initiation by measuring TSH and free T4.
Which of the following patients with thyroid gland enlargement
is LEAST likely to have a diagnosis of thyroid cancer?
a. A 5-year-old boy with two family members with medullary thyroid carcinoma
b. A 75-year-old man with a solitary nodule and hoarseness
c. A 56-year-old woman with a solitary nodule and a history of
radiation therapy to the neck
d. A 43-year-old woman with a diffuse goiter and tremor
e. A 14-year-old girl with an asymptomatic solitary nodule
d. A 43-year-old woman with a diffuse goiter and tremor
Thyroid cancer arising in the setting of Graves disease is uncommon
A 47-year-old woman presents to clinic for evaluation of weight gain, thinning hair, constant fatigue, constipation, and muscle weakness over the past year. She denies any prior history of thyroid disorders and currently takes no medications. Serum TSH level is elevated at greater than 30 mIU/L. What is the most likely cause of the patient’s symptoms?
a. Thyroid adenoma
b. Self-administration of thyroid hormone
c. Papillary thyroid carcinoma
d. Radioactive iodine administration
e. Hashimoto thyroiditis
e. Hashimoto thyroiditis
The clinical scenario classically describes the symptoms and biochemical findings of hypothyroidism. In the areas of the world with sufficient dietary iodine, the most common cause is Hashimoto thyroiditis.
A 75-year-old female is taken to the operating room for surgical excision of a 4- × 5-cm papillary thyroid cancer of the right lobe. Which of the following would be an indication for a right lateral compartment lymph node dissection?
a. Tumor size
b. History of radiation exposure
c. Positive central node on frozen section
d. Patient’s age
e. None of the above
e. None of the above
There is currently no role for lateral compartment lymph node dissection (LND) in papillary thyroid cancer if the nodes are not involved by imaging, biopsy, or clinical examination, that is, prophylactic LND. Prophylactic central compartment LND should be considered, however, in patients with high-risk features.
A 43-year-old female presents with a 2.5-cm thyroid nodule. Her serum TSH level is normal and FNA cytology is consistent with atypia of undetermined significance (AUS). Molecular testing reveals a somatic BRAF V600E mutation. What is the appropriate next step?
a. Germline genetic testing
b. Repeat fine-needle aspiration
c. Initiate vemurafenib therapy
d. Total or near-total thyroidectomy
e. Complete dermatologic examination to search for a melanoma primary
d. Total or near-total thyroidectomy
For indeterminant cytology on FNA (Bethesda categories III to V), molecular testing can add significant diagnostic value. In one series, 100% of thyroid FNA samples with either a BRAF V600E, RET/PTC, or PAX8/PPARγ mutation were malignant by postoperative histology; those with RAS mutations harbored malignancy in 85% of cases. These findings support total or near- total thyroidectomy in patients with Bethesda categories III to V cytology and a positive somatic mutation
A 16-year-old female presents with early satiety, postprandial vomiting, and epigastric distension for 3 weeks. She has presented to the ED multiple times. She endorses nervousness, difficulty sleeping, and unintentional weight loss for 3 months. CT of the abdomen and pelvis reveals a proximal small bowel obstruction with transition point at the third portion of the duodenum. What other findings is she most likely to have?
a. Cold sensitivity and bradycardia
b. Diffuse goiter and exophthalmos
c. Low serum iodine level
d. Increased urinary phosphate
e. Kidney stones and constipation
b. Diffuse goiter and exophthalmos
The CT findings described above are consistent with superior mesenteric artery syndrome, an uncommon disorder typically caused by abrupt weight loss, thinning of mesenteric fat, and subsequent compression of the duodenum at the aortomesenteric angle. In the majority of patients, particularly children and adolescents, a metabolic or behavioral cause should be sought. The catabolic state of Graves thyrotoxicosis can lead to such rapid involuntary weight loss. Most cases are treated by correcting the underlying disorder. Surgery is rarely indicated, but laparoscopic duodenojejunostomy is the operation of choice
Which of the following is the most common cause of Acute Thyroiditis?
a) Bacterial
b) Viral
c) Fungal
d) Protozoal
e) Autoimmune
a) Bacterial
Bacterial infections are the most common cause of acute thyroiditis with S. Aureus the most common bacterial organism.
To which of the following molecules do thyroxine esp. binds in serum?
a) Albumin
b) Thyroxine Binding Pre-Albumin
c) Thyroxine Binding Alpha-globulin
d) Thyroxine Binding Beta-globulin
e) Thyroxine Binding Gamma-globulin
c) Thyroxine Binding Alpha-globulin
Thyroxine mainly binds with the Thyroxine binding Alpha-globulin.
A middle aged female presented with swelling in front of neck that has developed over past few months. On examination, the swelling is unilateral and is of thyroid in origin. There are also few lymph nodes palpable along the side of swelling. What is your clinical diagnosis?
a) Metastatic Carcinoma
b) Non - Hodgkin Lymphoma
c) TB
d) Papillary Carcinoma
e) Medullary Carcinoma
d) Papillary Carcinoma
A 36-year-old female who underwent subtotal thyroidectomy complains of SOB 2hours after operation. What is the most likely cause?
a) Tension Hematoma
b) B/L RLN Injury
c) Tracheomalacia
d) Injury to Trachea
e) Pulmonary Embolism
a) Tension Hematoma
Tension Hematoma is the reactionary haemorrhage usually occurs 4-6 hours after surgery.
A 50-year-old female patient having huge multi-nodular goitre for past 14 years underwent total thyroidectomy. Just after extubation, patient developed dyspnea with visible supraclavicular and intercostal retractions. What is the most likely cause of patient’s respiratory distress?
a) Tracheomalacia
b) Tension Hematoma
c) Right RLN Injury
d) Injury to Parathyroid Glands
e) SLN Injury
a) Tracheomalacia
Long standing goitre [MNG] causes a chronic pull on tracheal rings. Following thyroidectomy, the release of chronic pull causes the tracheal rings to collapse when the ETT is removed. This is manifested as sudden onset of SOB immediately following extubation.
A young patient in her 3rd Trimester is found to have Graves Disease. What is the best treatment option for her?
a) Total Thyroidectomy
b) PTU
c) Methamizole
d) RAI
e) Subtotal Thyroidectomy
c) Methamizole
PTU is preferred in 1st Trimester.
Methamizole is preferred in 2nd & 3rd Trimester.
A female presents to OPD with complaints of midline neck swelling. On examination, the swelling is non-tender and can be moved side to side but not up and down. What is your diagnosis?
a) Lipoma
b) Cervical Lymph node
c) Thyroglossal Cyst
d) Sebaceous Cyst
e) Dermoid Cyst
c) Thyroglossal Cyst
They can move side to side but not up and down.
What is correct regarding position of thyroglossal duct cyst?
a) They are most commonly located just to the lateral of midline between thyroid isthmus above and hyoid bone below.
b) They are most commonly located in midline between thyroid isthmus and hyoid bone.
c) They are most commonly located in midline above the hyoid bone.
d) They are most commonly located at the base go tongue.
b) They are most commonly located in midline between thyroid isthmus and hyoid bone.
A patient with laboured breathing who has developed tension hematoma shortly after thyroidectomy will have which type of Acid-Base Disorder?
a) Respiratory Acidosis
b) Respiratory Alkalosis
c) Metabolic Acidosis
d) Metabolic Alkalosis
e) Metabolic Acidosis & Respiratory Acidosis
a) Respiratory Acidosis
Hematoma formation —– Upper Airway Obstruction —– CO2 Retention —— Respiratory Acidosis
A middle aged female presented with a solitary thyroid swelling. Which of the following is best investigation to be carried out for solitary thyroid swelling?
a) U/S
b) CT Scan
c) MRI
d) FNA
e) Isotope Scan
d) FNA
FNA is the single most important test used in evaluation of thyroid masses.
Which of the following is the most sensitive to detect recurrence of papillary carcinoma?
a) Serum T3 Levels
b) Serum T4 Levels
c) Serum TSH Levels
d) Serum thyroglobulin Levels
e) Serum Calcitonin Levels
d) Serum thyroglobulin Levels
Which of the following is most useful in monitoring response of thyroxine therapy?
a) Serum T3 Levels
b) Serum T4 Levels
c) Serum TSH Levels
d) Serum thyroglobulin Levels
e) Serum Calcitonin Levels
c) Serum TSH Levels
Levels of which of the following is most useful and accurate in thyroid profile?
a) Serum T3 Levels
b) Serum T4 Levels
c) Serum TSH Levels
d) Serum thyroglobulin Levels
e) Serum Calcitonin Levels
c) Serum TSH Levels
Which of the following clinical feature is indicative of thyroid malignancy?
a) Dyspnea
b) Dysphagia
c) Hard neck mass with mobile skin
d) Irregularly hard and fixed neck mass
e) Productive coUGH
d) Irregularly hard and fixed neck mass
A 39-year-old female underwent subtotal thyroidectomy for large toxic MNG. She presents 2 years later with development of nodularity at the site of operation. O/E, she is tachycardia with slightly raised BP and there is a nodular swelling palpable over the previous neck scar mark of previous operation. A diagnosis of recurrence of primary disease is suspected. H/P reports of previous specimen showed no malignant changes. Which of the following is appropriate treatment option in this patient?
a) RAI
b) Propanolol
c) ATDs
d) Near-total thyroidectomy
e) Total thyroidectomy
a) RAI
Subtotal thyroidectomy = Partial resection of each lobe, removing the bulk of the gland and leaving up-to 8 g of relatively normal tissue in each remnant.
Re-operation of recurrent nodular goitre is more difficult & dangerous. Therefore the most safer alternative is RAI. RAI can reduce the size of recurrent goitre.
A 36-year-old female presented with signs of hyperthyroidism with a large nodular goitre. A diagnosis of toxic MNG is made. What is the appropriate treatment in her case?
a) Radiotherapy
b) RAI
c) ATDs
d) Immediate total thyroidectomy
e) Preoperative preparation of patient with ATDs + BB & then perform total thyroidectomy.
e) Preoperative preparation of patient with ATDs + BB & then perform total thyroidectomy.
Young female presented with Medullary Carcinoma of thyroid gland. Her history is also suggestive of mother suffering from Breast Cancer. What genetic test will be appropriate?
a) RET
b) BRCA 1
c) BRCA 2
d) P53
e) PTEN
a) RET
A patient underwent near-total thyroidectomy now presents with Buffalo cough & voice change. Nerve injury?
a) RLN
b) ELN
c) ILN
d) SLN
A) RLN
During thyroidectomy, RLN is injured and identified per-operatively. What is the best management?
a) Nothing
b) Primary Repair
c) Nerve Graft
b) Primary Repair
Female patient with Painless gradual enlargement of hard thyroid gland. FNA is -ve for malignancy. X - Ray shows Tracheal Compression. Diagnosis?
a) De-quervain’s thyroiditis
b) Reidal thyroiditis
c) Follicular Adenoma
d) Autoimmune
e) Hurtle Cell
b) Reidal thyroiditis
Tracheal Compression is a feature of Reidal Thyroiditis
26 Year old female presented with Fever, severe neck pain. O/E, tender & firm neck mass can be appreciated. Thyroid Scan shows no uptake.
a) De-quervain’s Thyroiditis
b) Riedal thyroiditis
c) Hashimoto’s thyroiditis
a) De-quervain’s Thyroiditis
Retrosternal extension of thyroid. Best approach:
a) Transcervical
b) Median Sternotomy
a) Transcervical
26 Year-old female presented with goitre with retrosternal extension. Underwent surgery. RLN was identified & preserved during surgery. Post-operatively, she is breathless. Drain output is few cc. What is the cause of Breathlessness?
a) Pneumothorax
b) RLN Injury
c) Tension Hematoma
d) Tracheomalacia
d) Tracheomalacia
If breathlessness occurs immediately then; Tracheomalacia.
If it occurs after couple of hours, then; Tension Hematoma
A 55-year-old female presented with H/O Diarrhea, dysphagia & hoarseness of voice. On examination, there is B/L Cervical lymph nodes are enlarged. What biochemical investigation will you order to confirm your diagnosis?
Medullary CA.
Order Calcitonin levels.
R/O MEN 2 syndrome
Medullary CA with MEN Syndrome:
a) Prophylactic Total Thyroidectomy
b) Subtotal Thyroidectomy
c) Lobectomy + Isthumesectomy
a) Prophylactic Total Thyroidectomy
Thyroid Surgery with Antibiotic prophylaxis % of wound infection?
a) 1%
b) 0.5%
c) 2-3 %
d) 5 -10%
e) 20%
a) 1%
Medullary CA on FNAC. Treatment:
a) Total Thyroidectomy
b) Total Thyroidectomy + Central Neck Dissection
c) Subtotal Thyroidectomy
b) Total Thyroidectomy + Central Neck Dissection
H/P of thyroid tissue shows same cell pattern. Most likely diagnosis?
a) Anaplastic CA
b) Medullary CA
c) Papillary CA
d) Follicular CA
e) None of the above
d) Follicular CA
Suspicion of Malignancy in thyroid Management. Management:
a) Lobectomy
b) Total Thyroidectomy
c) Lobectomy + Isthumusectomy
c) Lobectomy + Isthumusectomy
Papillary CA with 2 cm nodule. Management:
a) Total Thyroidectomy
b) Total Thyroidectomy + RAI
a) Total Thyroidectomy
Post total-thyroidectomy, on the evening of procedure, patient is agitated with BP 140/90, Tachypnea & Tachycardia. What is the initial management?
a) 100% O2
b) Lugol Iodine
c) Fluids
d) Antithyroid drugs
e) BB
a) 100% O2
Total thyroidectomy done for huge MNG. After 48 hours, patient became dyspneic with stridor. What is the most likely cause?
a) Tension Hematoma
b) B/L RLN Paralysis
c) Hypocalcemia
d) Hypovolemia
a) Tension Hematoma
A patient presented with 2 cm mass in the right lobe of thyroid. Diagnosis of Medullary CA was done. What is the most appropriate management?
a) Total Thyroidectomy with Central Node Dissection
b) Right lobectomy + RAI
c) Chemoradiation
d) Surveillance
a) Total Thyroidectomy with Central Node Dissection
Patient with Medullary CA + Hypertension + Long fingers. Most likely diagnosis?
a) MEN 1
b) MEN 2A
c) MEN 2B
c) MEN 2B
10th POD after total thyroidectomy. Patient is on thyroxine. How to know if dose is enough or not?
a) Serum TSH
b) T3
c) T4
d) Serum Thyroxine Levels
a) Serum TSH
Patient presented with all signs & symptoms of hyperthyroidism. What is the best initial investigation?
a) Serum TSH
b) T3 & T4
c) U/S
d) FNA
a) Serum TSH
Female patient presented with weight loss, appetite increases & enlarged thyroid. Diagnosis?
a) Graves Disease
b) Toxic Adenoma
c) MNG
a) Graves disease
A patient with diffuse goitre with anti-thyroglobulin & anti-peroxidase antibodies +ve. Family history is positive for thyroid disease. What is the most likely diagnosis?
a) Graves disease
b) Hashimoto thyroiditis
b) Hashimoto thyroiditis
