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Surgery > Endocrine > Flashcards

Endocrine Flashcards

1
Q

Anatomy of the thyroid gland?

A

two triangular lobes connected by a central isthmus
found between C5-T1 within the pre-tracheal fascia

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2
Q

Anatomy of the parathyroid glands?

A

two pairs in total, found on the posterior aspect of the thyroid gland, within the pre-tracheal fascia

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3
Q

DDx for neck swelling?

A

congenital:
cystic hygroma
branchial cyst
thyroglossal cyst

inflammatory:
post-viral lymphadenopathy
bacterial/suppurative lymphadenopathy

neoplastic:
mets
salivary gland
lymphoma
lipoma
thyroid
carotid body tumours

goitre

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4
Q

Investigations in thyroid disease?

A

TFTs
autoantibodies
US
nuclear-imaging scintigraphy
CT neck non-contrast
FNAC

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5
Q

Features on US suggestive of malignant disease?

A

solid
irregular margins
microcalcifications
increased vascularity
size >5cm
lymphadenopathy

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6
Q

Indications for thyroidectomy?

A

cancer
compression of adjacent structures
cosmesis (goitre, eyes)
carbimazole or other medical treatment failure

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7
Q

Investigations for hyperthyroidism?

A

ECG (AFib, sinus tachycardia)
TFTs
autoantibodies
US
scintigraphy

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8
Q

Scintigraphy results in hyperthyroidism causes?

A

diffuse uptake -> Grave’s
patchy uptake -> TMG
single area of uptake -> solitary nodule

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9
Q

Mx of hyperthyroidism?

A

propranolol for symptoms
anticoagulation if AFib
carbimazole
propylthiouracil
radioiodine
surgery

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10
Q

Mx of Grave’s disease?

A

beta blockers symptomatic carbimazole for 18 months
propylthiouracil alternatively

if refractory -> radioiodine or surgery

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11
Q

Mx of TMG?

A

radioiodine therapy followed by surgery

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12
Q

Mx of solitary adenoma?

A

surgery followed by radioiodine treatment

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13
Q

Mx of thyroiditis?

A

analgesia (NSAIDs)
beta blockers

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14
Q

Features of Grave’s disease?

A

hyperthyroidism
smooth diffusely enlarged goitre
TSH receptor antibodies
thyroid eye disease
pretibial myxoedema
thyroid acropachy

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15
Q

Side effects of carbimazole/propylthiouracil?

A

teratogenic (C)
agranulocytosis
hepatoxicity (PTU)
rash, urticaria, arthralgia

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16
Q

Side effects of radioactive iodine?

A

hypothyroidism
transient thyroiditis
transient worsening of Graves’ ophthalmology

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17
Q

Options for thyroid surgery in hyperthyroidism?

A

thyroidectomy
subtotal thyroidectomy (risk of recurrence)

patients should be euthyroid prior to surgery

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18
Q

Types of thyroid cancer?

A

papillary
follicular
medullary
anaplastic

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19
Q

Features of papillary thyroid cancer?

A

most common
best prognosis
30-50 females
not encapsulated
may be partially cystic
2-10% will have metastatic disease at presentation (lungs, bone)

20
Q

Prognostic factors in papillary thyroid cancer?

A

prognosis generally quite good

younger age positive
smaller tumour positive
soft tissue invasion negative
distant mets negative

21
Q

RFs for papillary thyroid cancer?

A

radiation exposure
FHx

22
Q

RFs for follicular thyroid cancer?

A

radiation exposure
FHx
iodine deficiency

23
Q

Features of follicular thyroid cancer?

A

capsulated
don’t spread to LNs
haematogenous spread to bone and lungs
mets may be hormonally active -> hyperthyroidism

24
Q

Features of medullary thyroid cancer?

A

neuroendocrine tumour of C cells
produces calcitonin
sometimes produces CEA
may be sporadic or as part of MEN2
prior to surgery -> must be evaluated for other neuroendocrine tumours

25
Q

Features of anaplastic thyroid cancer?

A

older women with rapidly enlarging neck mass
aggressive and undifferentiated

palliative care early
no indication for surgical intervention
chemorads for symptomatic relief

26
Q

Investigations for thyroid cancer?

A

ECG
TFTs
FBC, U&E, LFTs
Imaging (US, scintigraphy, staging CT (no contrast!!)

27
Q

Mx of thyroid cancer?

A

MDT
thyroidectomy mainstay
(thyroid lobectomy in smaller cancers)
modified radical neck dissection if evidence of mets

can use radioiodine therapy following surgery to reduce micro-metastases
radiation used in anaplastic cancer for symptomatic relief

life-long levothyroxine replacement (higher-dose than for replacement therapy to suppress TSH as some tumours hormone dependent)

28
Q

Complications of thyroidectomy?

A

Early:
strap haematoma
transient hypoparathyroidism
hypocalcaemia
anaesthesia side effects
seroma
recurrent laryngeal nerve injury
vocal cord paresis

Intermediate:
infection

Late:
permanent hypoparathyroidism

29
Q

Mx of strap haematoma?

A

emergency as may lead to airway obstruction
immediate decompression by opening of deep wound layers before return to theatre

30
Q

Features of primary hyperparathyroidism?

A

85% due to solitary adenoma
10-15% due to hyperplasia of multiple glands, usually in the context of MEN syndromes

31
Q

Diagnosis of primary hyperparathyroidism?

A

high calcium
high of inappropriately normal PTH
incr. 24hr urinary calcium excretion (excludes familial hypocalciuric hypercalcaemia)
imaging to plan minimally invasive surgery

32
Q

Mx of primary hyperparathyroidism?

A

Acute:
correct calcium (IV fluids)
avoid bisphosphonates if surgery anticipated

Definitive:
parathyroidectomy
isolating responsible gland for minimally invasive surgery
intraoperative PTH measurement
serum calcium monitored post-op

33
Q

Presentation of primary hyperparathyroidism?

A

may be asymptomatic
bones
stones
moans
groans

34
Q

What is secondary hyperparathyroidism?

A

hyperplasia of all 4 glands due to chronic hypocalcaemia caused by:
CKD
Vit D deficiency

high PTH, low or normal calcium, high phosphate

35
Q

Mx of secondary hyperparathyroidism?

A

treat underlying cause

36
Q

What is tertiary hyperparathyroidism?

A

excess PTH secretion due to hyperplasia of the parathyroids due to prolonged secondary hyperparathyroidism after the underlying cause is addressed

high PTH, high Ca

37
Q

Mx of tertiary hyperparathyroidism?

A

parathyroidectomy of 3.5 glands

remaining 1/2 can be left in the neck or implanted into upper arm

38
Q

Causes of hyperparathyroidism?

A

primary
secondary
tertiary
malignant (PTHrP SCLC)

39
Q

Features of phaechromocytoma?

A

catecholamine-producing tumours of the neural crest
may be associated with MEN, VHL, NF
10% bilateral, 10% extra-adrenal, 10% familial

episodic headache, sweating, tachycardia
HTN

40
Q

Investigations for phaechromocytomas?

A

24-hr urine metanephrines
plasma metanephrines
CT/MRI

41
Q

Mx of phaechromocytoma?

A

alpha-block
beta-block
total adrenalectomy
if bilateral disease -> partial resection

42
Q

Causes of Cushing’s syndrome?

A

Cushing’s disease
Adrenal adenoma
Paraneoplastic
Exogenous steroids

43
Q

Investigations for Cushing’s syndrome?

A

cortisol levels
overnight dexamethasone suppression test
high-dose dexamethasone suppression test
ACTH
CT/MRI

44
Q

Mx of Cushing’s syndrome?

A

depends on cause

Iatrogenic:
taper down steroids
Cushing’s disease:
trans-sphenoidal surgery
Ectopic tumours:
excision

Adrenal adenoma:
surgical excision, unilateral adrenalectomy
bilateral adrenal hyperplasia:
bilateral adrenalectomy

45
Q

Post-op Mx of adrenalectomy?

A

cortisol replacement

bilateral -> lifelong glucocorticosteroid and mineralocorticosteroid

unilateral -> hydrocortisone post-op, oral prednisolone, may take months for cortisol levels to recover

46
Q

Investigations for Conn’s syndrome?

A

plasma aldosterone: renin ratio
adrenal vein sampling for localisation
CT/MRI

47
Q

Mx of Conn’s syndrome?

A

unilateral:
adrenalectomy
smaller lesions may allow partial adrenalectomy

bilateral:
medical therapy with aldosterone antagonist

Surgery (10 decks)

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