LE1

Question 1

Most common offending organism in otitis media:

A. S. pyogenes
B. S. aureus
C. P. aeruginosa
D. S. pneumoniae

Answer 1

D. S. pneumoniae
Rationale: Streptococcus pneumoniae is the most common cause of acute otitis media, as stated in Schwartz’s Principles of Surgery and other infectious disease references.

Question 2

Otologic condition with finding of granulation tissue along the floor of the external auditory canal near the bony cartilaginous junction:

A. Cholesteatoma
B. Acute otitis externa
C. Malignant otitis externa
D. St. Anthony’s fire

Answer 2

C. Malignant otitis externa
Rationale: Malignant otitis externa is characterized by granulation tissue at the bony-cartilaginous junction of the external auditory canal, a severe infection typically caused by Pseudomonas aeruginosa.

Question 3

True regarding Bell’s Palsy:

A. Majority of cases are idiopathic
B. Accompanied by other neurological deficits
C. Symptoms gradually arise for >72hrs
D. Complete recovery is the norm but not universal

Answer 3

A. Majority of cases are idiopathic
Rationale: Bell’s Palsy is primarily idiopathic, and while many patients recover completely, the majority of cases do not involve other neurological deficits, and symptoms typically arise suddenly, not gradually over more than 72 hours.

Question 4

Findings of chronic rhinosinusitis in nasal endoscopy, except:

A. Purulent mucus in the posterior ethmoid region
B. Edema in the middle meatus
C. Polyps in nasal cavity
D. All are correct

Answer 4

A. Purulent mucus in the posterior ethmoid region
Rationale: While purulent mucus, edema, and polyps can be findings in chronic rhinosinusitis, the posterior ethmoid region is not specifically noted for purulent mucus in typical cases of chronic rhinosinusitis.

Question 5

True of vascular malformations EXCEPT:

A. Always present at birth
B. Have hormonal growth spurts
C. Do not have a proliferative phase
D. Have an involution phase

Answer 5

C. Do not have a proliferative phase
Rationale: Vascular malformations are typically present at birth and may have growth spurts influenced by hormonal changes. They do not have a proliferative phase, which is characteristic of hemangiomas.

Question 6

True of congenital hemangiomas:

A. They proliferate up to 1 year of life
B. They may involute rapidly
C. Systemic steroids are usually needed
D. All are correct

Answer 6

D. All are correct
Rationale: Congenital hemangiomas can proliferate up to one year, may involute rapidly, and systemic steroids are sometimes used in treatment.

Question 7

Key step in repair of eyelid laceration to avoid mismatch:

A. Closure in Layers
B. Reapproximation of Orbicularis Oculi
C. Reapproximation of the conjunctival margin
D. Separating orbicularis oculi layer in closure

Answer 7

C. Reapproximation of the conjunctival margin
Rationale: Proper reapproximation of the conjunctival margin is crucial in eyelid laceration repair to prevent mismatches and ensure proper healing.

Question 8

Most common facial fracture:

A. Mandible bone

Answer 8

A. Mandible bone
Rationale: The mandible is the most commonly fractured bone in the face due to its prominence and exposed position.

Question 9

Midface fracture involving pterygoid plates posteriorly:

A. Le Fort I
B. Le Fort II
C. Le Fort III
D. All of the above

Answer 9

D. All of the above
Rationale: All Le Fort fractures (I, II, and III) involve the pterygoid plates posteriorly.

Question 10

Part of the oral cavity, EXCEPT:

A. Mucosal lip
B. Circumvallate papilla
C. Tonsilar pillars
D. Soft palate

Answer 10

A. Mucosal lip
Rationale: The mucosal lip is not considered part of the oral cavity proper, whereas the circumvallate papilla, tonsillar pillars, and soft palate are parts of the oral cavity.

Question 11

Criteria for defining second primary malignancy, except:

A. Histologic confirmation of malignancy in index tumor
B. Histologic confirmation of malignancy in secondary tumor
C. Two malignancies are separated by a mucosa of any condition
D. Possibility of SPM being a metastasis from the index tumor must be excluded
E. All are correct

Answer 11

C. Two malignancies are separated by a mucosa of any condition
Rationale: For defining a second primary malignancy (SPM), it is necessary to confirm histologically that both the index and secondary tumors are malignant and to exclude metastasis from the index tumor. The requirement of separation by mucosa is not a standard criterion.

Question 12

Most common histology of head and neck tumors:

A. Squamous Cell Carcinoma
B. Basal Cell Carcinoma
C. Papillary Carcinoma
D. Adenocarcinoma

Answer 12

A. Squamous Cell Carcinoma
Rationale: Squamous cell carcinoma is the most common histological type of head and neck tumors.

Question 13

Lesion with skip metastases:

A. Lip
B. Oral cavity
C. Oral tongue
D. Floor of the mouth

Answer 13

C. Oral tongue

Rationale: Oral tongue cancers are known for their propensity to exhibit skip metastasis, where the cancer cells spread to non-contiguous lymph nodes. This makes thorough evaluation and treatment planning crucial for oral tongue malignancies.

Question 14

True of lip cancer, except:

a. Most common in female
b. Most common in those with fairer complexions
c. Risk factors include tobacco use, immunosuppression, and UV exposure
d. Basal cell carcinoma and malignant melanoma are not uncommon

Answer 14

a. Most common in female
Rationale: Lip cancer is more common in males, particularly those with fair skin, and is associated with risk factors such as tobacco use, immunosuppression, and UV exposure. Basal cell carcinoma and malignant melanoma can occur in the lip.

Question 15

True of carcinoma of unknown primary, except:

A. 2-5% of all head and neck cancers
B. FNA preferred over open biopsy
C. PET-scan warranted if primary not identified on PE
D. All are correct

Answer 15

C. PET-scan warranted if primary not identified on PE
Rationale: Carcinoma of unknown primary accounts for 2-5% of head and neck cancers, and fine-needle aspiration (FNA) is preferred over open biopsy to avoid seeding tumor cells. However, a PET scan is warranted if the primary is not identified on physical examination and other imaging.

Question 16

A 50-year-old male, chronic smoker, came in with a 1 cm lesion on the lip, with discoloration and irregular border. There are no cervical lymph nodes identified in PE and imaging. Your treatment options include the following except:

a. Surgery
b. Radiation
c. Neck Dissection
d. All of the above

Answer 16

c. Neck Dissection
Rationale: For a small lip lesion with no evidence of cervical lymph node involvement, surgery and radiation are appropriate treatment options. Neck dissection is not indicated in the absence of lymph node involvement.

Question 17

Vocal cord lesion that almost always resolves with voice therapy:

A. Vocal fold nodule
B. Vocal fold cyst
C. Vocal fold polyp
D. Fibrous mass of the vocal fold

Answer 17

Answer: A. Vocal fold nodule
Rationale: Vocal fold nodules typically resolve with voice therapy, unlike cysts, polyps, or fibrous masses which may require surgical intervention.

Question 18

True for neck dissection for laryngeal cancer:

A. Dissection of submental to upper jugular chain nodes
B. Dissection of upper to lower jugular chain nodes
C. Dissection of upper to posterior triangle nodes
D. Dissection of upper to anterior compartment nodes

Answer 18

C. Dissection of upper to posterior triangle nodes
Rationale: Neck dissection for laryngeal cancer typically involves the dissection of nodes from the upper jugular chain to the posterior triangle.

Question 19

A 45-year-old male, chronic smoker, came in due to a 2-month history of anosmia and nasal obstruction. The patient also has a history of serious otitis media recently. Upon physical examination, there is also a mass in the posterolateral neck biopsy of which revealed malignancy. True regarding its diagnosis EXCEPT:

A. Associated with EBV
B. Associated with HPV
C. Advanced disease may present with cranial neuropathies
D. Distant metastatic disease is present in 5%

Answer 19

D. Distant metastatic disease is present in 5%
Rationale: Nasopharyngeal carcinoma, which can present with the symptoms described, is associated with EBV and sometimes HPV. Advanced disease can present with cranial neuropathies. However, distant metastatic disease is more common than 5% in advanced cases, making option D incorrect.

Question 20

True regarding nasopharyngeal carcinoma, except:

A. Typically well differentiated or lymphoepithelial SCC
B. Bilateral regional disease is common
C. CT scan is used to best assess soft tissue delineation
D. Recurrent tumors are treated with reirradiation

Answer 20

A. Typically well differentiated or lymphoepithelial SCC
Rationale: Nasopharyngeal carcinoma is often poorly differentiated or undifferentiated, and lymphoepithelial type is common. Bilateral regional disease is frequent, and CT scan is used to assess soft tissue involvement. Reirradiation is a common treatment for recurrent tumors.

Question 21

Management of patient with nasopharyngeal cancer stage I:

A. Palliative
B. Surgery
C. Chemoradiation
D. Hormonal

Answer 21

C. Chemoradiation
Rationale: For early-stage nasopharyngeal cancer, the standard treatment is radiation therapy alone, not chemoradiation. This discrepancy suggests a review of treatment protocols is necessary. However, for higher stages, chemoradiation is appropriate.

Question 22

Most common malignant salivary gland tumor:

A. Mucoepidermoid carcinoma
B. Adenoid cystic carcinoma
C. Pleomorphic adenoma
D. Adenocarcinoma

Answer 22

A. Mucoepidermoid carcinoma
Rationale: Mucoepidermoid carcinoma is the most common malignant tumor of the salivary glands.

Question 23

An 8-year-old boy with sore throat for 1 day, no fever, no difficulty swallowing, weakly, cannot tolerate medications:

Answer: Advise some conservative treatment and closely follow up patient

Answer 23

Answer: Advise some conservative treatment and closely follow up patient
Rationale: For a child with a mild sore throat and no alarming symptoms, conservative management with close follow-up is appropriate.

Question 24

A 1-year-old boy with a 2x2 cm bluish maculopapular, soft, compressible, nonpulsatile mass present since birth and more prominent when crying:

Answer: Infantile hemangioma

Answer 24

Rationale: The description fits an infantile hemangioma, a common benign vascular tumor in children that often becomes more prominent with crying.

Question 25

A 50-year-old female with hoarseness of voice, no tobacco use, but post-laparoscopic cholecystectomy with foreign body sensation in throat, lesion on posterior larynx:

A. Vocal Fold Nodule
B. Laryngeal granuloma
C. Vocal fold polyp
D. Fibrous mass of the vocal fold

Answer 25

B. Laryngeal granuloma
Rationale: The description of a lesion on the posterior larynx after intubation is characteristic of a laryngeal granuloma, often caused by irritation or trauma from intubation.

Question 26

True regarding unilateral cord paresis except:

A. Commonly iatrogenic in origin
B. Should include autoimmune serology workup
C. May present with stridor and weak cry in children
D. CT scan is the mainstay of treatment

Answer 26

D. CT scan is the mainstay of treatment
Rationale: Unilateral vocal cord paresis is often iatrogenic (e.g., post-surgical), may require an autoimmune serology workup if the cause is not clear, and can present with stridor and weak cry in children. CT scan is not the mainstay of treatment but is used for diagnostic purposes.

Question 27

A 23-year-old patient with a pulsating mass on the right temporal area post-brawl:

a. Give antibiotics since it may be due to infection of injury he might have sustained during the brawl
b. Request imaging studies to further investigate
c. Do needle biopsy due to the possibility of malignancy
d. Observe since the mass is most likely to be a hematoma and the pulsation is the artery beneath the hematoma

Answer 27

b. Request imaging studies to further investigate
Rationale: A pulsating mass could indicate a vascular injury such as a pseudoaneurysm, so imaging studies are necessary to investigate further.

Question 28

Indications for admission of patients undergoing tonsillectomy EXCEPT:

A. Strongly suspected OSA
B. Patients with craniofacial abnormalities
C. >3 years of age
D. O2 saturation of 80%

Answer 28

C. >3 years of age
Rationale: Age greater than 3 years is not an indication for admission, while OSA, craniofacial abnormalities, and low O2 saturation are.

Question 29

Surgical management of thyroglossal duct cyst:

a. Aspiration and excision for recurrence
b. Marsupialization of the cyst
c. Excision of cyst including the hyoid bone involvement
d. None: Antibiotics alone will do

Answer 29

c. Excision of cyst including the hyoid bone involvement
Rationale: The Sistrunk procedure, which includes the excision of the cyst along with the middle part of the hyoid bone, is the standard treatment.

Question 30

Most common site of mandibular fracture:

A. Condyle
b. Coronoid process
c. Body
d. Angle

Answer 30

A. Condyle
Rationale: The condyle is the most common site of fracture in the mandible.

Question 31

Cancer sites with metastases in level III or IV lymph nodes EXCEPT:

A. Tip of the tongue
b. Anterior 1/3 of the tongue
c. Anterior 2/3 of the tongue
s. Posterior 1/3 of the tongue

Answer 31

A. Tip of the tongue
Rationale: The tip of the tongue typically metastasizes to level I or II nodes first, not levels III or IV.

Question 32

A 50-year-old male with a 10-year mass between the left cheek and ear, enlarged over time:

A. Pleomorphic Adenoma
B. Mucoepidermoid Carcinoma
C. Adenoid Cystic Carcinoma
D. Adenocarcinoma

Answer 32

A. Pleomorphic Adenoma
Rationale: Pleomorphic adenoma is the most common benign tumor of the parotid gland and fits the description given

Question 33

Optimal surgical management of mucoepidermoid carcinoma of the parotid gland:

A. Enucleation
B. Superficial parotidectomy
C. Total parotidectomy
D. Total parotidectomy with neck dissection

Answer 33

D. Total parotidectomy with neck dissection
Rationale: High-grade mucoepidermoid carcinomas often require total parotidectomy with neck dissection due to their aggressive nature and potential lymph node involvement.

Question 34

True of salivary gland tumors except:

A. Majority arise in the parotid
B. Adenoid cystic carcinoma has a propensity for neural invasion
C. The larger the gland, the higher the propensity for malignancy
D. Typically well-circumscribed and slow-growing masses

Answer 34

C. The larger the gland, the higher the propensity for malignancy
Rationale: The larger the salivary gland, the lower the propensity for malignancy. Malignancies are more common in the smaller salivary glands.

Question 35

Site of salivary gland tumor with the highest risk for malignancy:

A. Minor salivary gland
B. Sublingual gland
C. Submandibular gland
D. Parotid gland

Answer 35

A. Minor salivary gland
Rationale: Tumors of the minor salivary glands have the highest risk of being malignant.

Question 36

True regarding levels of cervical lymph nodes except:

A. Lip Level I, II, III
B. Hypopharynx Level II, III, IV
C. Thyroid Level II, III, IV, V
D. All are correct

Answer 36

A. Lip Level I, II, III
Rationale: The lymphatic drainage for the lip primarily involves Level I nodes. Levels II and III may be involved in more advanced disease but are not primary drainage sites.

Question 37

True regarding reconstruction in the head and neck except:

A. Local flaps are commonly used for cutaneous reconstruction in the head and neck
B. Skin grafts cannot be utilized in oral cavity
C. The majority of major defects of the head and neck require free tissue transfer for optimal reconstruction
D. All are true

Answer 37

B. Skin grafts cannot be utilized in oral cavity
Rationale: Skin grafts can be used in the oral cavity for reconstruction purposes, making statement B incorrect.

Question 38

Palliative care for head and neck cancer includes the following, except:

A. Tracheostomy
B. Gastrostomy tube placement
C. Radiotherapy
D. All are correct

Answer 38

D. All are correct
Rationale: All listed options can be part of palliative care for head and neck cancer, making answer D incorrect since they are correct.

Question 39

Follow up care/Surveillance for head and neck tumor includes the following except:

a. History and PE every 12 months on the 5th and subsequent year after
b. History and PE every 4 months on the second to 4th year after treatment
c. History and PE 3-4th months for the first year after treatment
d. All are correct

Answer 39

d. All are correct
Rationale: The follow-up schedule described in all the options is accurate according to standard surveillance protocols for head and neck tumors, making answer d incorrect because they are all correct.

Question 40

In a person with suspected hyperthyroidism, the single diagnostic test to request is:

A. Thyroid scan
B. TSH assay
C. Free T3
D. Free T4
E. FNAB

Answer 40

B. TSH assay
Rationale: TSH assay is the most sensitive initial test for diagnosing hyperthyroidism. Low TSH levels indicate hyperthyroidism.

Question 41

All of the following statements concerning radioactive iodine treatment for Graves’ disease are correct, except:

A. It is a painless procedure
B. It is indicated for patients who are poor risk for surgery
C. The incidence of hypothyroidism is greater than with surgical treatment
D. The incidence of hypothyroidism is decreased by giving frequent small doses
E. Thyroid storm is a complication

Answer 41

D. The incidence of hypothyroidism is decreased by giving frequent small doses
Rationale: Frequent small doses of radioactive iodine do not decrease the incidence of hypothyroidism; in fact, hypothyroidism is a common outcome of this treatment.

Question 42

A 30/F presents with a 2 cm anterior neck mass on the left that moves with deglutition. On PE, the mass is soft with no associated cervical lymphadenopathy. Patient has no other signs and symptoms. Appropriate management is:

A. FNAB
B. TSH determination
C. Thyroid scan
D. TSH suppression with thyroid hormone

Answer 42

B. TSH determination
Rationale: TSH determination is an appropriate initial test to evaluate thyroid function and assess for thyroid disease.

Question 43

In the patient above, a trial of thyroid hormone suppression was tried. After 2 months, there was no note of decrease in size of the mass. As the surgeon, you will recommend:

A. Continue thyroid hormone suppression for 2 months
B. Thyroid lobectomy
C. Total thyroidectomy
D. RAI therapy

Answer 43

B. Thyroid lobectomy
Rationale: Thyroid lobectomy is indicated for a persistent thyroid mass after hormone suppression therapy, especially if there is suspicion of a benign or malignant tumor.

Question 44

A 35/M presents at the OPD due to an enlarging anterior neck mass of 1 month duration. On PE, there was note of hoarseness and dysphagia. The most probable diagnosis is:

A. Papillary CA
B. Anaplastic CA
C. Follicular CA

Answer 44

B. Anaplastic CA
Rationale: Anaplastic carcinoma of the thyroid typically presents with rapid growth, hoarseness, and dysphagia, and is more common in older patients, although it can occur in younger patients as well.

Question 45

40/F presents with an anterior neck mass of 2 years duration. On PE 3x4 cm firm mass and moves with deglutition. There is also an incidental finding of a 3x3 cm scalp mass over R occipital area. The most likely diagnosis is:

A. Follicular
B. Medullary
C. Papillary
D. Anaplastic

Answer 45

C. Papillary
Rationale: Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer and often presents with firm, mobile masses that can move with deglutition. PTC commonly metastasizes to cervical lymph nodes and can occasionally present with distant metastasis like a scalp mass.

Question 46

A patient with a 2x2 thyroid papillary CA presented with a solitary lymph node on level III. A complete surgery will consist of:

A. Total thyroidectomy and excision of LIII node
B. Total thyroidectomy with selective node dissection (II, III, IV, V, VI)
C. Total thyroidectomy with radical neck dissection
D. Near total thyroidectomy with selective node dissection (II, III, IV)

Answer 46

A. Total thyroidectomy and excision of LIII node
Rationale: For papillary thyroid carcinoma with isolated lymph node metastasis, the standard treatment includes total thyroidectomy and excision of the affected lymph node.

Question 47

Patient has a low T3 and T4, increased uptake on thyroid scan:

a. Hashimoto’s
b. Iron deficiency goiter
c. Grave’s
d. ALL

Answer 47

c. Grave’s
Rationale: Graves’ disease typically presents with low TSH and elevated T3 and T4, along with increased uptake on a thyroid scan. Low T3 and T4 with increased uptake is atypical but can occur in early treatment or unusual cases.

Question 48

A patient with Graves’ Disease was sent at the OPD Clinic, restless, jaundiced, febrile to touch with HR of 150 beats per minute. Before sending the patient to ER, you were informed that there were available tablets of PTU and saturated solution of iodine at the OPD. How should you administer these medications?

A. PTU 1st before iodine
B. Iodine 1st followed by PTU
C. PTU and iodine all given at the same time
D. NOTA

Answer 48

A. PTU 1st before iodine
Rationale: PTU (propylthiouracil) should be given first to inhibit thyroid hormone synthesis before administering iodine, which helps to reduce thyroid hormone release.

Question 49

Which of the following hormones is preferred for treatment after total thyroidectomy?

A. Liothyronine
B. Iodized salt
C. Levothyroxine
D. Iodine

Answer 49

C. Levothyroxine
Rationale: Levothyroxine (synthetic T4) is the preferred treatment for maintaining normal thyroid hormone levels after total thyroidectomy.

Question 50

Which of the following statements is false regarding CA of thyroid origin?

A. Papillary and follicular CA tend to be slow growing
B. Most common in papillary (70%)
C. Anaplastic least common (5%)
D. Follicular carcinoma’s most common cause is radiation exposure to the head and neck

Answer 50

D. Follicular carcinoma’s most common cause is radiation exposure to the head and neck
Rationale: Radiation exposure is a well-known risk factor for papillary thyroid carcinoma, not follicular carcinoma. Follicular carcinoma is more associated with iodine deficiency.

Question 51

Which of the following early signs and symptoms cannot be found in a patient with hypothyroidism?

a. Arthralgia and myalgia
b. Pallor with poor mucosal turgor
c. Hyperactive DTR’s
d. Cold intolerance

Answer 51

c. Hyperactive DTR’s
Rationale: Hypothyroidism typically presents with hypoactive deep tendon reflexes (DTRs), not hyperactive DTRs.

Question 52

Which is not a component of Grave’s disease?

A. Myxedema
B. Diffuse Goiter
C. Pretibial Edema
D. Pretrial

Answer 52

A. Myxedema
Rationale: Myxedema is associated with hypothyroidism, not Graves’ disease. Graves’ disease is characterized by diffuse goiter, pretibial edema, and other hyperthyroid symptoms.

Question 53

If your patient has many questions about her disease, what will you tell her?

A. Follicular CA has a worse prognosis than papillary CA
B. Follicular CA metastasizes through the lymphatics
C. Papillary CA has an association with her iodine intake
D. Anaplastic CA has the best prognosis among the thyroid carcinomas

Answer 53

A. Follicular CA has a worse prognosis than papillary CA
Rationale: Follicular carcinoma generally has a worse prognosis than papillary carcinoma because it tends to metastasize hematogenously. Papillary carcinoma has a good prognosis, and anaplastic carcinoma has the worst prognosis.

Question 54

RF 37/F consulted you for doubling of vision and dizziness 1 1/2 yrs ago. She has a gradual enlarging anterior neck mass. 1 year ago she began to experience tremors, palpitations, and weight loss even with voracious appetite. 9 months ago symptoms abated when she became pregnant, until 1 week ago when she experienced palpitation and anxiety. To evaluate the patient you ordered TSH and free T4. What would be your expected finding?

A. TSH low, uncombined T4 high
B. TSH normal, uncombined T4 high
C. TSH low, uncombined T4 high
D. TSH and uncombined T4 normal

Answer 54

A. TSH low, uncombined T4 high
Rationale: The correct option is A: “TSH low, uncombined T4 high” indicates hyperthyroidism, which aligns with her symptoms of tremors, palpitations, weight loss, and anxiety.

Question 55

A 38-year-old female came to the OPD for a sore throat. She describes the pain as aching throat pain, which radiates to the jaw. She has a 3-day history of intermittent fever, malaise, and colds. PE shows nonhyperemic pharyngeal mucosa, normal tonsils, tender CLAD, non-enlarged anterior neck mass. What is true of the patient’s diagnosis?

A. Increased ESR, low thyroid scan uptake
B. 3 distinct phases: hypothyroid, thyrotoxic, recovery
C. The definitive cause is viral infection

Answer 55

A. Increased ESR, low thyroid scan uptake
Rationale: Subacute thyroiditis typically presents with increased ESR and low thyroid scan uptake.

Question 56

What is true regarding levothyroxine?

A. Desiccated animal thyroid preparations are superior to levothyroxine
B. Safe to take up to 3 missed doses
C. Taken after meals
D. Ok to take with Ca supplements

Answer 56

B. Safe to take up to 3 missed doses
Rationale: Levothyroxine should be taken on an empty stomach, not after meals, and calcium supplements should be taken several hours apart from levothyroxine. Taking up to 3 missed doses at once is sometimes acceptable but should be done with caution and under medical advice.

Question 57

What would you use to monitor papillary thyroid cancer to see if your treatment (RAI) is working?

A. Thyroglobulin
B. TSH
C. T4

Answer 57

A. Thyroglobulin
Rationale: Thyroglobulin levels are used to monitor for recurrence or persistence of papillary thyroid cancer after treatment.

Question 58

What is TRUE about the treatment of thyroid cancer?

A. All well-differentiated thyroid cancers should be surgically excised
B. Lobectomy is associated with a higher incidence of hypothyroidism
C. Most tumors are already TSH-resistant, eliminating the option of levothyroxine suppression for thyroid malignancies
D. Chemotherapy with multiple agents, such as anthracyclines and paclitaxel, has been found to be effective for anaplastic thyroid cancer

Answer 58

A. All well-differentiated thyroid cancers should be surgically excised
Rationale: Surgical excision is the standard treatment for well-differentiated thyroid cancers. Chemotherapy is generally not effective for anaplastic thyroid cancer, and lobectomy typically has a lower incidence of hypothyroidism compared to total thyroidectomy.

Question 59

Case: 39-year-old woman, with a 6-month history of fatigue, heat intolerance, palpitations, and a 5 kg weight loss despite a ravenous appetite. She also noticed a slowly growing anterior neck mass. Her periods are still regular but have become scanty. True or False: Patient is expected to have periorbital edema.

Answer: TRUE

Answer 59

TRUE
Rationale: The symptoms described are indicative of hyperthyroidism, possibly Graves’ disease, which can include periorbital edema due to thyroid eye disease.

Question 60

You requested for FT4 (elevated) and a TSH (suppressed). Based on these values, you conclude that your patient’s condition is:

A. Primary
B. Secondary
C. Tertiary
D. NOTA

Answer 60

A. Primary
Rationale: Elevated FT4 with suppressed TSH indicates primary hyperthyroidism, where the problem originates in the thyroid gland itself.

Question 61

You proceed to advise her on the different modes of managing her condition. In general, you can offer the following, except:

a. Total thyroidectomy
b. Antithyroid drugs
c. Radioactive iodine therapy
d. None of the above

Answer 61

a. Total thyroidectomy
Rationale: Total thyroidectomy is typically reserved for patients with large goiters, suspected malignancy, or those who cannot tolerate other treatments. The other options (antithyroid drugs and radioactive iodine therapy) are standard treatments for hyperthyroidism.

Question 62

She chose to take Propylthiouracil 50 mg/tab, 2 tabs 3x a day. What laboratory parameter(s) will you use to monitor her response to treatment?

a. FT4
b. TSH
c. Anti-TPO
d. A and B

Answer 62

d. A and B
Rationale: Both FT4 and TSH levels are used to monitor the response to treatment in hyperthyroidism. Anti-TPO antibodies are more relevant for diagnosing autoimmune thyroid diseases rather than monitoring treatment.

Question 63

Which among the following is a rare but major side effect of antithyroid drugs?

A. Rash
B. Urticaria
C. Hepatitis
D. Arthralgia

Answer 63

C. Hepatitis
Rationale: Hepatitis is a rare but serious side effect of antithyroid drugs like propylthiouracil and methimazole. Rash, urticaria, and arthralgia are more common but less severe side effects.

Question 64

Which of the following thyroid cancers is associated with MEN syndrome?

A. Papillary
B. Follicular
C. Medullary
D. Anaplastic

Answer 64

C. Medullary
Rationale: Medullary thyroid carcinoma is associated with Multiple Endocrine Neoplasia (MEN) syndromes, particularly MEN 2A and 2B.

Question 65

Antithyroid drugs must be stopped at least 3 days before administration of radioactive iodine to achieve optimum iodide uptake.

A. True
B. False

Answer 65

A. True
Rationale: Antithyroid drugs should be stopped before administering radioactive iodine to ensure optimal uptake of the radioiodine by the thyroid gland.

Question 66

All well-differentiated thyroid cancers should be surgically excised.

A. True
B. False

Answer 66

A. True
Rationale: Surgical excision is the standard treatment for well-differentiated thyroid cancers (papillary and follicular).

Question 67

Breastfeeding and pregnancy are relative contraindications to radioiodine intake.

A. True
B. False

Answer 67

B. False
Rationale: Breastfeeding and pregnancy are absolute contraindications to radioiodine therapy, not relative ones. The risk to the fetus and the nursing infant from radiation exposure is significant.

Question 68

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 from intrathoracic vessels
C. Most can be resected by 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

Answer 68

C. Most can be resected by cervical incision
Rationale: Substernal goiters are usually extensions of the thyroid gland into the mediastinum and can often be resected through a cervical incision. They are not typically primary mediastinal goiters, do not respond well to thyroid suppression, and do not usually require prophylactic tracheostomy unless there is severe tracheal compression

Question 69

Hyperplasia of the parathyroid gland occurs in chronic renal disease because there is:

A. Excessive loss of potassium in the urine
B. Excessive loss of calcium in the urine
C. Excessive loss of phosphate in the urine
D. Excessive loss of sodium in the urine
E. Impaired calcium absorption from the gut

Answer 69

E. Impaired calcium absorption from the gut
Rationale: In chronic renal disease, there is impaired activation of vitamin D, leading to reduced calcium absorption from the gut, which results in secondary hyperparathyroidism.

Question 70

Which of the following is true regarding secondary hyperparathyroidism?

A. Serum calcium levels are markedly increased
B. It is usually associated with a parathyroid adenoma
C. PTH levels are typically normal or high normal
D. Cinacalcet is the initial treatment of choice
E. Most patients will eventually require parathyroidectomy

Answer 70

C. PTH levels are typically normal or high normal
Rationale: In secondary hyperparathyroidism, often seen in chronic kidney disease, PTH levels are elevated in response to hypocalcemia. Serum calcium levels are typically normal or low. Cinacalcet and other treatments are used to manage the condition, but not all patients require parathyroidectomy.

Question 71

All of the following are true regarding pseudohypoparathyroidism except:

A. It is the result of a genetic defect
B. The serum calcium is low
C. The serum phosphate level is elevated
D. It responds well to exogenously administered PTH extract

Answer 71

D. It responds well to exogenously administered PTH extract
Rationale: Pseudohypoparathyroidism is characterized by the body’s resistance to PTH, leading to low serum calcium and high phosphate levels. It does not respond well to exogenous PTH because the issue lies in the target tissue response, not in the hormone itself.

Question 72

A 45-year-old man with episodic severe hypertension is found to have elevated plasma metanephrines and a serum calcium level of 11.5 mg/dL. Which of the following would be indicated in the work-up?

A. CT scan of the sella turcica
B. Calcitonin level
C. Serum gastrin level
D. Serum prolactin level
E. A 24-hour urine cortisol

Answer 72

B. Calcitonin level
Rationale: Elevated plasma metanephrines suggest a pheochromocytoma, and the elevated serum calcium suggests possible hyperparathyroidism. This combination is consistent with Multiple Endocrine Neoplasia type 2 (MEN 2), which is associated with medullary thyroid carcinoma. Calcitonin level is a marker for medullary thyroid carcinoma.

Question 73

When comparing total thyroidectomy for well-differentiated papillary thyroid cancer with unilateral thyroidectomy and isthmusectomy, all of the following are true, EXCEPT:

A. Total thyroidectomy facilitates detection of metastatic disease via 131I scanning
B. Total thyroidectomy decreases recurrence rates in patients with a history of radiation exposure
C. Total thyroidectomy increases the risk of postoperative hypocalcemia
D. Total thyroidectomy facilitates detection of recurrent disease via thyroglobulin levels
E. Total thyroidectomy improves overall survival

Answer 73

E. Total thyroidectomy improves overall survival
Rationale: Total thyroidectomy facilitates detection of metastatic disease and recurrence via 131I scanning and thyroglobulin levels. It also decreases recurrence rates and increases the risk of postoperative hypocalcemia. However, there is no strong evidence that total thyroidectomy improves overall survival compared to more conservative surgical approaches in all patients with well-differentiated thyroid cancer.

Question 74

Which of the following conditions is characterized by the formation of colloid nodules or adenomas in the thyroid gland due to increased TSH stimulation?

A. Hashimoto’s thyroiditis
B. Endemic goiter
C. Toxic goiter
D. Non-toxic goiter

Answer 74

D. Non-toxic goiter

Question 75

Which of the following statements is true about Toxic Multinodular Goiter (TMG)?

A. It typically occurs in younger individuals with a history of nontoxic multinodular goiter.
B. Hyperthyroidism in TMG often presents suddenly and is easily detected.
C. Symptoms are similar to Grave’s Disease but without extrathyroidal manifestations.
D. RAI uptake is usually decreased in TMG.

Answer 75

C. Symptoms are similar to Grave’s Disease but without extrathyroidal manifestations.

Question 76

Which of the following is a primary cause of hypothyroidism characterized by decreased free T4 (fT4) levels and increased TSH levels?

A. Pituitary tumor
B. Hypothalamic insufficiency
C. Hashimoto’s thyroiditis
D. Turner’s syndrome

Answer 76

C. Hashimoto’s thyroiditis

Question 77

When considering RAI (Radioactive Iodine) therapy for patients with thyroid conditions, which of the following patients should not receive RAI treatment due to absolute contraindications?

A. Older patients with small or moderate-sized goiters
B. Patients who have relapsed after medical or surgical therapy
C. Women who are pregnant or planning pregnancy within 6 months of treatment
D. Patients with thyroid nodules

Answer 77

C. Women who are pregnant or planning pregnancy within 6 months of treatment

Question 78

Which of the following is an indication for tonsillectomy in children?

A. 3 documented episodes of tonsillitis per year
B. Peritonsillar abscess
C. Single antibiotic allergy
D. PFAPA (Periodic fever, aphthous stomatitis, pharyngitis, adenitis)

Answer 78

B. Peritonsillar abscess

Question 79

Which of the following is an exclusion criterion for outpatient tonsillectomy in children?

A. Age 5 years or older
B. Lives within 30 minutes from the hospital
C. No comorbidities
D. Obstructive Sleep Apnea (OSA)

Answer 79

D. Obstructive Sleep Apnea (OSA)

Question 80

Which of the following statements is true regarding vocal cord paralysis?

A. The right vocal cord is more commonly involved than the left.
B. Indirect mirror exam cannot be used for visualization.
C. Injury to the recurrent laryngeal nerve can cause unilateral vocal cord paralysis.
D. Speech therapy is not an option for managing vocal cord paralysis.

Answer 80

C. Injury to the recurrent laryngeal nerve can cause unilateral vocal cord paralysis.

Question 81

A patient with Grave’s disease was sent at the OPD clinic, restless, jaundiced, febrile to touch with HR of 150 beats per minute. Before sending the patient to ER, you were informed that there were available tablets of PTU and saturated solution of iodine at the OPD. How should you administer these medications?

A. PTU 1st before iodine
B. Iodine 1st followed by PTU
C. PTU and iodine all given at the same time
D. NOTA

Answer 81

A. PTU 1st before iodine

Rationale:
According to Schwartz, in the management of a thyroid storm or severe hyperthyroidism, antithyroid drugs such as Propylthiouracil (PTU) should be administered first to inhibit thyroid hormone synthesis and peripheral conversion of T4 to T3. Iodine should be given at least an hour later to inhibit the release of thyroid hormones. Administering iodine first can lead to an initial increase in thyroid hormone synthesis, worsening the condition.

Question 82

Most common thyroid cancer?

A. Papillary thyroid cancer

Answer 82

A. Papillary thyroid cancer

Rationale:
Schwartz states that papillary thyroid carcinoma is the most common type of thyroid cancer, accounting for about 80-85% of all thyroid malignancies. It typically has a good prognosis and can often be treated successfully with surgery and radioactive iodine.

Question 83

Hormone for treatment after total thyroidectomy

A. Levothyroxine

Answer 83

A. Levothyroxine

Rationale:
According to Schwartz, after a total thyroidectomy, the patient will require lifelong thyroid hormone replacement therapy. Levothyroxine, a synthetic form of the thyroid hormone T4, is the standard treatment used to maintain normal metabolism and prevent hypothyroidism.

Question 84

Used to monitor papillary thyroid cancer to see if RAI is working?
A. Thyroglobulin

Answer 84

A. Thyroglobulin

Rationale:
Schwartz mentions that thyroglobulin is a protein produced by thyroid tissue, including most papillary thyroid carcinomas. After thyroidectomy and RAI treatment, thyroglobulin levels should be very low or undetectable. Persistent or rising levels of thyroglobulin indicate residual or recurrent disease.

Question 85

Hyperplasia of the parathyroid gland with chronic renal disease due to

A. Impaired calcium absorption by the gut

Answer 85

A. Impaired calcium absorption by the gut

Rationale:
Schwartz explains that in chronic kidney disease (CKD), hyperplasia of the parathyroid glands often occurs due to secondary hyperparathyroidism. This condition results from impaired calcium absorption by the gut due to reduced production of active vitamin D by the kidneys and phosphate retention, leading to hypocalcemia and increased parathyroid hormone (PTH) secretion.

Question 86

A 30-year-old with a 2 cm anterior neck mass on the left that moves with deglutition, mass is soft with no cervical lymphadenopathy. Management?

A. FNAB
B. Thyroid scan
C. TSH determination

Answer 86

A. FNAB (Fine Needle Aspiration Biopsy)

Rationale:
Schwartz recommends Fine Needle Aspiration Biopsy (FNAB) as the initial diagnostic test for evaluating thyroid nodules, especially those that are palpable and move with deglutition. FNAB is a minimally invasive procedure that can provide cytological diagnosis to distinguish between benign and malignant nodules.

Question 87

Female with 2x2 thyroid papillary CA with solitary lymph nodes on level III. Surgery will consist of

A. Total thyroidectomy with selective node dissection

Answer 87

A. Total thyroidectomy with selective node dissection

Rationale:
According to Schwartz, the standard surgical treatment for papillary thyroid carcinoma (PTC) with nodal involvement includes a total thyroidectomy along with selective dissection of the involved lymph node compartments to reduce the risk of recurrence and improve disease-free survival.

Question 88

Thyroid showing psammoma bodies and lung metastasis

A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4

Answer 88

D. Stage 4

Rationale:
Schwartz describes that the presence of distant metastasis, such as to the lungs, in thyroid cancer typically classifies the disease as Stage 4. Psammoma bodies are characteristic of papillary thyroid carcinoma, and lung metastasis indicates advanced disease, warranting a Stage 4 classification.

Question 89

You see to monitor papillary thyroid CA to see if RAI is working

A. Thyroglobulin

Answer 89

A. Thyroglobulin

Rationale:
Schwartz states that thyroglobulin is a protein produced by thyroid tissue, including most papillary thyroid carcinomas. Monitoring thyroglobulin levels after radioactive iodine (RAI) treatment helps assess the effectiveness of the treatment and detect any recurrence of the disease.

Question 90

Associated with MEN syndrome

A. Medullary
B. Papillary

Answer 90

A. Medullary

Rationale:
Schwartz explains that medullary thyroid carcinoma (MTC) is associated with Multiple Endocrine Neoplasia (MEN) syndromes, particularly MEN2A and MEN2B. MTC arises from the parafollicular C cells of the thyroid gland, which are involved in these genetic syndromes.

Question 91

Key step in repair of eyelid laceration to avoid mismatch

A. Closure in layers
B. Reapproximation of orbicularis oculi
C. Reapproximation of the conjunctival margin
D. Separating orbicularis oculi layer in closure

Answer 91

B. Reapproximation of orbicularis oculi

Rationale:
Schwartz indicates that precise reapproximation of the orbicularis oculi muscle is crucial in repairing eyelid lacerations to ensure proper alignment and function, avoiding mismatches and preserving the integrity of the eyelid.

Question 92

Most common facial fracture

A. Mandible
B. Masseter
C. Zygomatic
D. NOTA

Answer 92

A. Mandible

Rationale:
According to Schwartz, mandibular fractures are the most common type of facial fracture due to the prominence and exposed position of the mandible. These fractures often result from trauma to the lower face.

Question 93

Which of the following is the most common malignancy associated with Epstein-Barr virus (EBV)?

A. Hodgkin lymphoma
B. B-Cell lymphoma
C. T-cell lymphoma

Answer 93

A. Hodgkin lymphoma

Rationale:
Schwartz states that Epstein-Barr virus (EBV) is strongly associated with Hodgkin lymphoma. EBV is found in the malignant Reed-Sternberg cells characteristic of this type of lymphoma, making it the most common EBV-associated malignancy.

Question 94

Which of the following malignancies is associated with human papillomavirus (HPV)?

A. Cervical cancer
B. Anal cancer
C. Vulvar cancer
D. Vaginal cancer

Answer 94

A. Cervical cancer

Rationale:
Schwartz explains that human papillomavirus (HPV) is the primary cause of cervical cancer. High-risk types of HPV, particularly types 16 and 18, are strongly linked to the development of cervical cancer.

Question 95

Site of salivary gland tumor with the highest risk for malignancy

A. Minor salivary gland
B. Sublingual gland
C. Submandibular gland
D. Parotid gland

Answer 95

A. Minor salivary gland

Rationale:
Schwartz mentions that tumors in the minor salivary glands have the highest risk of malignancy. As the size of the salivary gland decreases, the likelihood of the tumor being malignant increases, with minor salivary gland tumors being more frequently malignant compared to larger glands.

Question 96

True of lip cancer, except:

A. Most common in female
B. Most common in those with fair complexions
C. Risk factors include tobacco use
D. Immunosuppression, and UV exposure
E. Basal cell carcinoma and malignant melanoma are not uncommon

Answer 96

A. Most common in female

Rationale:
Schwartz states that lip cancer is most common among men, particularly those with fair complexions who are exposed to UV light and use tobacco. Basal cell carcinoma and malignant melanoma can occur on the lips, but squamous cell carcinoma is the most common type.

Question 97

A 50-year-old male, chronic smoker, came in with a 1 cm lesion on the lip, with discoloration and irregular border. There are no cervical lymph nodes identified in PE and imaging. Your treatment options include the following except

A. Surgery
B. Radiation
C. Neck Dissection
D. All of the above

Answer 97

C. Neck Dissection

Rationale:
According to Schwartz, in the absence of cervical lymph node involvement, the primary treatment for a small lip lesion with discoloration and irregular borders (which suggests malignancy) would typically involve surgery, possibly followed by radiation depending on the margins and pathology. Neck dissection is not indicated if there are no clinically or radiographically evident lymph node metastases.

Question 98

True for neck dissection for laryngeal cancer

A. Dissection of submental to upper jugular chain nodes
B. Dissection of upper to lower jugular chain nodes
C. Dissection of upper to posterior triangle nodes
D. Dissection of upper to anterior compartment nodes

Answer 98

B. Dissection of upper to lower jugular chain nodes

Rationale:
Schwartz outlines that the standard neck dissection for laryngeal cancer often involves removing lymph nodes from the upper to lower jugular chain (levels II-IV) to address potential metastatic spread.

Question 99

Offending agent in acute otitis externa:

A. Pseudomonas aeruginosa

Answer 99

A. Pseudomonas aeruginosa

Rationale:
Schwartz identifies Pseudomonas aeruginosa as the most common pathogen responsible for acute otitis externa, also known as swimmer’s ear.

Question 100

Most common intracranial complication in otitis media:

A. Meningitis

Answer 100

A. Meningitis

Rationale:
According to Schwartz, meningitis is the most common intracranial complication of otitis media, resulting from the spread of infection to the meninges.

Question 101

The following cancer may have metastases in level III or IV lymph nodes with or without involvement of the upper nodes of the neck (level I and II), except

A. Tip of the tongue
B. Ant. ⅓ of the tongue
C. Ant. ⅔ of the tongue
D. Post. ⅓ of the tongue

Answer 101

A. Tip of the tongue

Rationale:
Schwartz indicates that cancers of the anterior two-thirds of the tongue (including the tip) tend to metastasize to level I and II lymph nodes initially. Cancers of the posterior tongue can metastasize to levels III and IV directly. The tip of the tongue is less likely to have skip metastases to levels III or IV without first involving the upper nodes.

Question 102

The following are true except:

A. Local flaps are commonly used for cutaneous reconstruction in the head and neck
B. Skin grafts cannot be utilized in oral cavity
C. The majority major defects of the head and neck require free tissue transfer for optimal reconstruction
D. All are true

Answer 102

B. Skin grafts cannot be utilized in oral cavity

Rationale:
According to Schwartz, skin grafts can be utilized in the oral cavity for reconstruction, especially for smaller defects. Therefore, statement B is incorrect, while the other statements are true.

Question 103

A 50-year-old male, chronic smoker, came in with a 1 cm lesion on the lip, with discoloration and irregular border. There are also small masses under the chin. Your treatment options include the following:

A. Surgery
B. Radiation
C. Neck dissection
D. All of the above

Answer 103

D. All of the above

Rationale:
Schwartz suggests that in the presence of clinically apparent lymph node metastases (masses under the chin), the treatment for a malignant lip lesion would include surgery for the primary lesion, radiation therapy to control local disease, and neck dissection to manage regional lymph node metastasis.

Question 104

A 45-year-old male chronic smoker came in due to a 2-month history of anosmia and nasal obstruction. The patient also has a history of serous otitis media recently. Upon physical examination, there is also a mass in the posterolateral neck. What is your next step?

A. Request for CT or MRI
B. Do endoscopy for further evaluation
C. Excise mass on the neck
D. RT PCR swab for COVID-19, 14-day quarantine, re-swab after quarantine

Answer 104

A. Request for CT or MRI

Rationale:
Schwartz recommends imaging studies such as CT or MRI as the next step for a thorough evaluation of a patient presenting with nasal obstruction, anosmia, and a neck mass, particularly to assess the extent of the disease and plan further management.

Question 105

Question 83:
A 1-year-old boy was brought in by his mother with a complaint of a mass on his face approximately 2x2 cm bluish and maculopapular in character, soft, compressible, and nonpulsatile. According to his mother, this lesion has been present since birth but seems to be growing with the patient and seems to be more prominent when the patient is crying. What is the probable diagnosis?

A. Congenital hemangioma
B. Infantile hemangioma
C. Port wine stain
D. Arteriovenous malformation
E. Option

Answer 105

B. Infantile hemangioma

Rationale:
According to Schwartz, infantile hemangiomas are common vascular tumors in infants that are usually present at birth or appear within the first few weeks of life. They typically grow rapidly during the first year (proliferative phase) and then gradually involute. These hemangiomas are soft, compressible, and become more prominent with crying due to increased blood flow.

Question 106

Mass in the Rosenmuller - Management?

A. Radiotherapy
B. Chemotherapy
C. Surgical management
D. Adjuvant therapy

Answer 106

A. Radiotherapy

Rationale:
Schwartz mentions that nasopharyngeal carcinoma, which commonly arises in the Rosenmuller fossa, is primarily treated with radiotherapy due to the anatomic location and radiosensitivity of the tumor. Surgery is not typically feasible due to the difficulty of accessing this area surgically.

Question 107

Frequent throat clearing

A. Goiter

Answer 107

A. Goiter

Rationale:
Frequent throat clearing can be a symptom associated with goiter due to the enlargement of the thyroid gland, which can cause irritation and a sensation of something being stuck in the throat, leading to frequent attempts to clear it.

Question 108

2 cm lip lesion, no nodal or distant metastasis. What is the staging?

A. Stage I
B. Stage II
C. Stage III
D. Stage IV

Answer 108

A. Stage I

Rationale:
According to Schwartz, a 2 cm lip lesion without nodal or distant metastasis would be classified as Stage I. Stage I typically involves small, localized tumors without regional or distant spread.

Question 109

Lower lip lesion involving ⅓ of the lip commissure (Same case given by Doc during the case presentation)

A. Resection with reconstruction
B. Resection without reconstruction
C. Resection, reconstruction, radiotherapy

Answer 109

A. Resection with reconstruction

Rationale:
Schwartz explains that for lesions involving a significant portion of the lip, such as the commissure, resection with reconstruction is necessary to ensure both oncologic control and functional and aesthetic outcomes. This often involves surgical excision followed by reconstructive techniques to restore lip function and appearance.

Question 110

A 4-year-old male is brought by his mother for consultation for an anterior neck mass. The mass has been present since birth. The mass has regressed recently but is growing back to its size after a week. The mass worsens with cough and is erythematous. What is the management for this patient?

A. Aspiration and excision for recurrence

Answer 110

A. Aspiration and excision for recurrence

Rationale:
Schwartz suggests that a congenital neck mass that has shown regression and subsequent growth with symptoms of inflammation, such as erythema and worsening with cough, may be indicative of a thyroglossal duct cyst or another congenital lesion. Aspiration can help diagnose the nature of the cystic fluid, and surgical excision is typically required to prevent recurrence and treat the underlying pathology.