Masters of Surgery

Question 1

Side effect of carbimazole and propylthiouracil?

Answer 1

Agranulocytosis (massive decrease in WBC)

Question 2

What should you give people before thyroidectomy for hyperthyroidism?

Answer 2

Lugols iodine (potassium iodide) (reduces vascularity of gland)
Beta-blocker to block the cardiovascular and CNS symptoms of the thyrotoxicosis

Question 3

Complications of thyroidectomy surgery

Answer 3

Haemorrhage (can cause respiratory distress by tracheal compression)
Hypocalcemia (caused by damage to parathyroid glands)
Recurrent laryngeal nerve injury

Question 4

Which fascia is the thyroid gland in?

Answer 4

The pretrachial fascia

Question 5

Thyroglossal tract

Answer 5

Connects back of tongue to the thyroid gland

Question 6

Key steps in evaulation of thyroid nodule or goitre?

Answer 6

Thyroid function tests (TSH, T3 and free T4)
Fine Needle Aspiration Cytology (FNAC):
-determines whether the follicular cells are benign, suspicious or malignant

Other useful tests:

• Thyroid ultrasound (cystic vs. nodule)
• Thyroid isotope scan –> useful if there is a solitary nodule and suppressed TSH, to look for a solitary toxic adenoma

Question 7

Treatment of solitary thyroid nodule? (hint FNAC)

Answer 7

Treatment depends on FNAC result
If benign, the nodule can be left alone and repeat FNAC in 6-12 months
If FNAC is suspicious –> thyroid lobectomy is carried out as a quarter of these nodules are malignant
If FNAC is frankly malignant –> total thyroidectomy
If FNAC reveals a cyst:
small cyst (4cm) treated by thyroid lobectomy because of risk of malignancy

Question 8

Papillary carcinoma

Answer 8

Most common and best prognosis
Disease spread to the lymph nodes and by direct invasion into the neck
Distant metastases are uncommon

Question 9

Follicular carcinoma

Answer 9

Tumour develops later in life than papillary carcinoma

Spread mainly via the blood stream with distant metastases to bones, liver and brain

Question 10

Medullary carcinoma

Answer 10

This is uncommon and develops from the calcitonin-secreting parafollicular cells
SOMETIME ASSOCIATED WITH TUMOURS IN THE PARATHYROID AND ADRENAL GLANDS –> MEN2

Question 11

There may be a history of irradiation to the head and neck during childhood or a family history of thyroid carcinoma?

Answer 11

Thyroid cancer, shocker

Question 12

Diagnosis of thyroid cancer

Answer 12

Thyroid function tests
FNAC
Chest radiograph (to look for pulmonary metastasis)

Question 13

A high serum calcium level coupled with a low serum phosphate level is highly suggestive of what?

Answer 13

(primary) hyperparathyroidism

Question 14

Parathyroid hormone effects on calcium and phosphate?

Answer 14

Mobilises calcium from bone
Reduced renal calcium excretion
Promotes renal phosphate excretion

Question 15

Causes of primary hyperparathyroidism

Answer 15

Single parathyroid adenoma (most common: 85%)
Generalised parathyroid hyperplasia (15%)
Parathyroid carcinoma (1%)

Question 16

Secondary hyperparathyroidism

Answer 16

This develops as a result of some of the complex metabolic changes associated with chronic renal failure, which tend to produce a low calcium level

Question 17

Hypokalaemia and hypertension

Answer 17

Aldosteronism

Question 18

This can present as a hypertensive crisis with sweating, palpitations, severe headache and occasionally an MI or cerebrovascular incident?

Answer 18

Phaeochromocytoma

Question 19

This can present insidiously with diastolic hypertension

Answer 19

Phaeochromoctyoma

Question 20

Treatment of Phaechromocytoma

Answer 20

Usually, alpha-adrenergic blockade (phenoxybenzamine) is started some time before surgery, with agents such as nitroprusside and propanolol being used to control blodd pressure and heart rate during the operation

Question 21

Questions you should ask when taking a thyroid history?

Answer 21

Family history of thyroid disease
Past medical history of neck irradiation
Any history of hoarseness

• ask the patient to swallow
• ask the patient to stick out his tongue

Question 22

Most common cause of subperiostal bone resorption in the phalanges?

Answer 22

Hyperparathyroidism

Question 23

Hot and cold thyroid nodules?

Answer 23

Hot nodules usually associated with hyperthyroidism

Cold nodules usually associated with malignancy (or simple cysts)

Question 24

Type of thyroid cancer that usually metastasises to the bone?

Answer 24

Follicular

Question 25

Hyperaldosteronism and renin levels?

Answer 25

Low renin in PRIMARY hyperaldosteronism

High renin in SECONDARY hyperaldosteronism (caused by hepatic or renal disease)

Question 26

A patient with Cushing syndrome may be diabetic?

Answer 26

True

Glucose intolerance and fasting hyperglycemia are common in Cushing syndrome

Question 27

Measuring urea and electrolyes (low potassium)
Increased plasma aldosterone
Decreased plasma renin

Answer 27

Primary hyperaldosteronism