Multiple Choice Questions

PAPILLARY CARCINOMA 10. About papillary carcinoma true statement is/are:

a. Radiation is a risk factor (PGI Nov 2010)
1. A 35 years old female presented with a swelling in the neck b. Multifocal
for the past 2 months, she had the treatment for Hodgkin’s c. Hematogenous spread is common
lymphoma when she was 22 years with irradiation. On, d. Distant metastasis is seen
examination, her vitals were normal, there was a single, firm,
irregular nodule, moving with deglutition in the left side of 11. Most common thyroid malignancy is:
midline. Clinical examination also revealed a single node in (DNB 2012, MHPGMCET 2002)
the left side of the neck. The most likely clinical diagnosis of a. Anaplastic carcinoma b. Follicular carcinoma
this condition is: (COMEDK 2011) c. Medullary carcinoma d. Papillary carcinoma
a. Recurrence of lymphoma 12. Which thyroid malignancy is common after radiation
b. Malignant goiter exposure?  (Recent Question 2016, MHSSMCET 2005)
c. Benign multinodular goiter a. Follicular b. Papillary
d. Toxic nodular goiter c. Medullary d. Anaplastic
2. Most probable pathological diagnosis would be: 13. A 10 years old boy presented with cervical lymph adenopathy.
 (COMEDK 2011) Needle biopsy from the nodes revealed secondaries from
a. Anaplastic carcinoma b. Follicular carcinoma papillary carcinoma of thyroid. The child under went
c. Medullary carcinoma d. Papillary carcinoma complete removal of tumor near total thyroidectomy and
3. The FNAC of the lesion should reveal: (COMEDK 2011) radical neck dissection. What should be the immediate next
a. ‘Orphan-Annie eye’ nucleus cells line of management? (All India 2012)
b. Amyloid deposits a. Start thyroxine suppression therapy
c. Epitheloid cells and giant cells b. I-131 whole body scan to assess the extent of disease
d. Follicular cells c. Bone scan to evaluate secondaries
4. The ideal treatment of the above condition would be: d. CECT scan to assess any residual disease
a. Total thyroidectomy with lymph nodal dissection of the 14. Orphan Annie-eye nuclei seen in: (Orissa 2011)
same side (COMEDK 2011) a. Papillary carcinoma of thyroid
b. Radiotherapy b. Medullary carcinoma of thyroid
c. Lobectomy c. Anaplastic carcinoma of thyroid
d. Lobectomy with isthmusectomy d. Follicular carcinoma of thyroid
5. About papillary carcinoma what is/are true? (PGI Dec 2008) 15. Psammoma bodies are seen in following except: (PGI 2002)
a. Often encapsulated a. Serous cystadenoma of ovary
b. Prognosis is bad b. Mucinous cystadenoma of ovary
c. Lymph node metastases is common c. Meningioma
d. Can metastasize to lung d. Papillary carcinoma of thyroid
e. Multiple foci of tumour is seen 16. Which of the following would be the best treatment for
6. Variant of papillary carcinoma thyroid: (PGI June 2007) a 2 cm thyroid nodule in a 50 years old man with FNAC
a. Medullary b. Warthin revealing it to be a papillary carcinoma? (All India 2009)
c. Columnar d. Insular a. Hemithyroidectomy (Recent Question 2015)
e. Diffuse sclerosing b. Subtotal thyroidectomy with modified neck dissection
7. Which of the following would be the best treatment for c. Near total thyroidectomy with modified neck dissection
a 2 cm thyroid nodule in a 50-year-old man with FNAC d. Hemithyroidectomy with modified neck dissection
revealing it to be a papillary carcinoma? (AIIMS May 2011) 17. True regarding papillary carcinoma of thyroid:
a. Hemithyroidectomy
a. Undifferentiated carcinoma  (MCI March 2006)
b. Total thyroidectomy with left sided modified neck
b. Blood-borne metastasis is commoner
dissection
c. Excellent prognosis
c. Near total thyroidectomy with radiotherapy
d. Capsulated
d. Hemithyroidectomy with modified neck dissection
18. Which type of thyroid carcinoma has the best prognosis?
8. Psammoma bodies may be seen in all of the following, (DNB 2010, All India 96)
except: (Recent Question 2016, All India 2011) a. Papillary carcinoma b. Anaplastic carcinoma
a. Follicular carcinoma of thyroid c. Follicular carcinoma d. Medullary carcinoma
b. Papillary carcinoma of thyroid
19. Compared to follicular carcinoma, papillary carcinoma of
c. Meningioma
thyroid have: (PGI Dec 2007, June 2005, Dec 2006)
d. Serous cystadenocarcinoma of ovary
a. More male preponderance
9. Features of papillary carcinoma includes: (PGI May 2011) b. Bilaterality
a. FNAC easy b. Almost always unifocal c. Local recurrence common
c. Psammoma body d. Spread to cervical LN d. Increased lymph node metastasis
e. Bad prognosis e. Increased mortality
 66 Surgery Essence

20. Occult thyroid malignancy with nodal metastasis is: FOLLICULAR CARCINOMA
(DNB 2005, 2001, AIIMS Sept 96)
a. Medullary carcinoma b. Follicular carcinoma 32. All of the following are true for follicular carcinoma of
c. Papillary carcinoma d. Anaplastic carcinoma thyroid except: (COMEDK 2006)
a. Lymph node involvement rare
21. Least malignant thyroid cancer is: (AIIMS Nov 2003) b. Vascular involvement common
a. Papillary carcinoma b. Follicular carcinoma c. Younger patients have good prognosis
c. Anaplastic carcinoma d. Medullary carcinoma d. Diagnosis by FNAC
22. Lateral aberrant thyroid refers to: (AIIMS June 2002) 33. Thyroid carcinoma with pulsating vascular skeletal
a. Congenital thyroid abnormality metastasis is: (COMEDK 2007, All India 95)
b. Metastatic foci from primary in thyroid a. Follicular b. Anaplastic
Endocrine Surgery

c. Struma ovarii c. Medullary d. Papillary

d. Lingual thyroid
34. Follicular carcinoma of thyroid is due to mutation of:
23. Which of the following is used in the treatment of a. RAS b. HGF (JIPMER 2010)
differentiated thyroid cancer? (All India 2006) c. RET d. ABL
a. I-131 b. 99mTc
35. A well differentiated follicular carcinoma of thyroid can be
c. P-32 d. I-131 MIBG
best differentiated from a follicular adenoma by:
24. In treatment of papillary carcinomas thyroid, radioiodine a. Hurthle cell change (All India 2011, 2009)
destroys the neoplastic cells predominantly by: b. Lining of tall columnar and cuboidal cells
 (AIIMS Nov 2005) c. Vascular invasion
a. X-rays b. Beta rays d. Nuclear features
c. Gamma rays d. Alpha particles
36. FNAC is useful in all the following types of thyroid
25. A 21 years old woman has 3 cm node in the lower deep carcinoma except: (UPPG 2010, MCI March 2005, All India 95)
cervical chain on the left. The biopsy is interpreted as a. Papillary b. Follicular
revealing normal thyroid tissue in a lymph node. The most c. Anaplastic d. Medullary
likely diagnosis is:  (DNB 2012, DPG 2009 Feb)
a. Subacute thyroiditis 37. Most probable malignancy that develops in a case of long-
b. Metastatic carcinoma thyroid standing goiter is: (MCI June 2018, Recent Question 2015,
c. Hashimoto’s disease  Kerala PG 2015, AIIMS Feb 97, Nov 2001)
d. Lateral aberrant thyroid a. Follicular carcinoma b. Anaplastic carcinoma
c. Papillary carcinoma d. Medullary carcinoma
26. All of the following regarding papillary carcinoma thyroid
is true except: (All India 90) 38. Bone metastasis is common in which thyroid tumor:
a. Multicentric origin a. Follicular b. Papillary(AIIMS Nov 99)
b. Secondaries to lymph nodes c. Hurthle cell tumour d. Anaplastic
c. Slowing growing 39. Thyroid nodule of 4 cm size, mobile but causing compressive
d. Bony metastasis in early stage
symptoms. All are true except: (DNB 2011)
27. Most common type of carcinoma thyroid having least chances a. FNAC is investigation of choice
of hematogenous spread: (Recent Question 2015) b. FNAC cannot distinguish follicular adenoma from carci-
a. Follicular b. Papillary noma
c. Anaplastic d. Medullary c. Managed by sub-total thyroidectomy
28. Chance of metastasis to lymph nodes in PTC: d. Cold nodules are diagnostic of malignancy
 (Recent Question 2017) 40. In case of adenomatoid goiter which carcinoma is commonest
a. <10% b. 10–20%
to occur: (AIIMS Nov 98)
c. 20–40% d. >60%
a. Medullary carcinoma b. Follicular carcinoma
29. Orphan-Annie eye nuclei is seen in: (Recent Question 2017) c. Papillary carcinoma
a. Papillary carcinoma thyroid d. Anaplastic carcinoma
b. Follicular carcinoma thyroid
c. Medullary carcinoma thyroid 41. Carcinoma thyroid with blood borne metastasis is:
d. Anaplastic carcinoma thyroid a. Follicular b. Papillary(AIIMS Feb 97)
c. Medullary d. Anaplastic
30. Psammoma bodies are seen in: (Recent Question 2017)
a. Papillary carcinoma thyroid 42. Lymph node metastasis is least commonly seen with:
Section 1

b. Follicular carcinoma thyroid a. Papillary CA Thyroid  (All India 94)

c. Medullary carcinoma thyroid b. Medullary CA Thyroid
d. Thyroid lymphoma c. Follicular CA Thyroid
31. A 27-year-old lady with 20 weeks pregnancy presented with d. Anaplastic CA Thyroid
a thyroid nodule on right side. FNAC from the nodule was 43. A 20 years old female patient presented with a thyroid
suggestive of papillary carcinoma. Which of the following is swelling. Most probably, the fine needle aspiration cytology
contraindicated in her management? (AIIMS May 2017) will not diagnose: (AIIMS Nov 97)
a. Total thyroidectomy plus neck node dissection a. Papillary carcinoma of thyroid
b. Right lobectomy b. Medullary carcinoma of thyroid
c. Radioactive iodine ablation c. Non-Hodgkin’s lymphoma of thyroid
d. Total thyroidectomy d. Follicular carcinoma of thyroid
 Thyroid 67

44. Hurthle cells tumour is: (WBPG 2012, DPG 2007) 56. Medullary carcinoma thyroid arises from: (AIIMS Nov 93)
a. Papillary carcinoma thyroid a. Parafollicular cells b. Cells lining the acini
b. Follicular carcinoma thyroid

Section 1
c. Capsule of thyroid d. Stroma of the gland
c. Medullary carcinoma thyroid
57. A biopsy from a mass in front of the neck revealed
d. Anaplastic carcinoma
parafollicular cells. How do you follow up? 
45. Metastasis from follicular carcinoma should be treated by:
 (JIPMER November 2017)
a. Radioiodine b. Surgery (MCI Sept 2006)
a. Calcitonin b. T4
c. Thyroxine d. Observation
c. Thyroxine d. Thyroglobulin
46. True regarding follicular carcinoma of thyroid:
58. Treatment of medullary carcinoma thyroid:
a. Hematogemous spread (JIPMER 2014, 2013)
a. Surgery and radiotherapy (AIIMS Nov 2008)
b. Commonly multifocal
b. Radiotherapy and chemotherapy
c. Readily diagnosed by face
c. Surgery only
d. Most commonly carcinoma of thyroid d. Radioiodine ablation
47. The microscopic feature that differentiates a follicular 59. Needle biopsy of solitary thyroid nodule in a young woman
carcinoma from a follicular adenoma: (COMEDK 2014) with palpable cervical lymph nodes on the same sides
a. Nuclear pleomorphism demonstrates amyloid in stroma of lesion. Likely diagnosis is:
b. Hurthle cell change a. Medullary carcinoma thyroid  (All India 2002)
c. Capsular invasion b. Follicular carcinoma thyroid
d. Absence of colloid c. Thyroid adenoma
48. FNAC cannot detect which of the following? d. Multinodular goiter
 (AIIMS November 2014) 60. In medullary carcinoma thyroid tumour marker is:
a. Follicular carcinoma b. Papillary carcinoma  (WBPG 2014, AIIMS June 98)
c. Colloid goiter d. Hashimoto’s thyroiditis a. TSH b. Calcitonin
c. T3, T4 and TSH d. Alpha Fetoprotein
MEDULLARY CARCINOMA 61. After thyroidectomy for medullary carcinoma of thyroid,
which is important for determining recurrence of tumour?
49. Screening method of medullary carcinoma thyroid is: a. Thyroglobulin b. TSH (MCI Sept 2009)
a. Serum calcitonin (All India 97, AIIMS Nov 95) c. CEA d. Thyroxine levels
b. Serum calcium 62. The expression of the following oncogene is associated with
c. Serum alkaline phosphate a high incidence of medullary carcinoma of thyroid:
d. Serum acid phosphatase  (AIIMS Nov 2005)
50. Treatment of medullary carcinoma thyroid: a. p53 b. Her-2-neu
a. Surgery and Radiotherapy  (AIIMS May 2011) c. Ret proto-oncogene d. Rb gene

Endocrine Surgery
b. Radiotherapy and Chemotherapy
63. A 26 years old women presents with a palpable thyroid nodule,
c. Surgery only
and needle biopsy demonstrates amyloid in the stroma of the
d. Radioiodine ablation
lesion. A cervical lymph node is palpable on the same side as
51. False statement about feature of MTC: (PGI Nov 2011) the lesion. The preferred treatment should be:
a. Familial MTC may presents in 2nd decade a. Removal of the involved node, the isthmus, a portion of
b. It has characteristic amyloid stroma the opposite bone and he enlarged lymph node
c. Secrete serotonin b. Removal of the involved lobe, the isthmus, a portion of the
d. Take up radioiodine opposite lobe, and he enlarged lymph node
e. Secrete calcitonin c. Total thyroidectomy and modified neck dissection on the
52. Thyroid radioiodine ablation therapy is useful in all except: side of the enlarged lymph node
a. Recurrent papillary carcinoma (PGI May 2011) d. Total thyroidectomy and irradiation of the cervical lymph
b. Residual papillary carcinoma nodes (BIHAR PG 2014, All India 2002)
c. Anaplastic carcinoma
64. Amyloid stroma is seen in which carcinoma thyroid:
d. Follicular carcinoma
a. Papillary carcinoma (AIIMS June 2000)
e. Medullary carcinoma
b. Medullary carcinoma
53. Age for prophylactic thyroidectomy in MEN IIB syndrome? c. Anaplastic carcinoma
 (MHSSMCET 2009) d. Follicular carcinoma
a. 1 month b. 2 months
65. A patient has pituitary tumour and pheochromocytoma and
c. 4 months d. 6 months
a thyroid nodule. Which carcinoma is most likely to occur?
54. Recommended age for prophylactic thyroidectomy for MEN-2  (AIIMS Nov 2000)
is:  (Recent Question 2015) a. Follicular carcinoma b. Medullary carcinoma
a. 5 years b. Before 1 year c. Papillary carcinoma d. Anaplastic carcinoma
c. At the time of diagnosis d. Any time 66. A 52 years old female patient presents with symptoms of
55. Thyroid carcinoma associated with hypocalcemia is: pheochromocytoma. She also has a thyroid carcinoma. Her
 (AIIMS Dec 94) thyroid carcinoma is of which type: (AIIMS June 99)
a. Follicular carcinoma b. Medullary carcinoma a. Anaplastic b. Medullary
c. Anaplastic carcinoma d. Papillary carcinoma c. Follicular d. Papillary
 68 Surgery Essence

67. MEN-2 is seen with the following type of thyroid carcinoma: ANAPLASTIC CARCINOMA
a. Papillary b. Medullary (All India 97)
c. Anaplastic d. Follicular 80. Not true about anaplastic thyroid carcinoma:
a. Local infiltration common  (PGI May 2011)
68. Serum calcitonin is a marker for: (DNB 2003, All India 94) b. Spread by lymphatic route
a. Anaplastic carcinoma b. Papillary carcinoma c. Long term survival in patient undergoing surgery
c. Medullary carcinoma d. Follicular carcinoma d. Surgery is of limited value
69. Treatment of choice for medullary carcinoma of thyroid is: e. Highly chemosensitive
(AIIMS May 2005) 81. A patient with long standing multinodular goitre develops
a. Total thyroidectomy b. Partial thyroidectomy hoarseness of voice and swelling undergoes sudden increase
c. I-131 ablation d. Hemithyroidectomy in size. Likely diagnosis is:
Endocrine Surgery

70. All of the following are helpful for diagnosis of medullary  (Recent Question 2014, All India 2001)
carcinoma thyroid except: (PGI 2000) a. Follicular carcinoma b. Papillary carcinoma
a. Spindle cell stroma with few follicles c. Medullary carcinoma d. Anaplastic carcinoma
b. Amyloid deposition
82. The treatment of choice for anaplastic carcinoma of thyroid
c. Calcitonin in stroma
infiltrating trachea and sternum will be:  (AIIMS Nov 2005)
d. Histological mitochondria is essential for diagnosis
a. Radical excision b. Chemotherapy
71. Which of the following gene defects is associated with c. Radiotherapy
development of medullary carcinoma of thyroid? d. Palliative/Symptomatic treatment
a. Ret proto-oncogene b. FAP gene (All India 2004)
c. Rb gene d. BRCA-1 gene 83. Least common thyroid malignancy is: (Recent Question 2015)
72. Commonest presenting complaints of medullary carcinoma a. Papillary b. Follicular
thyroid: (PGI 84) c. Medullary d. Anaplastic
a. Diarrhea b. Dysphagia
c. Hoarseness d. Flushing THYROID METASTASIS
73. Which of the following is true about medullary carcinoma?
a. Calcitonin is not a marker (DPG 2008) 84. Metastasis in thyroid gland come most commonly from
b. Arises from parafollicular C cells carcinoma of: (PGI June 98)
c. Produces PTH a. Testis b. Prostate
d. Take up radioiodine c. Breast d. Lungs
74. True about medullary carcinoma thyroid: (DPG 2007)
THYROID LYMPHOMA
a. Good prognosis
b. Associated with MEN-1 85. All of the following are true about lymphoma of the thyroid
c. Increased calcitonin is not associated with hypocalcemia except: (All India 2007)
d. Treated by near total thyroidectomy a. More common in females
b. Slow growing
75. All are true regarding medullary carcinoma of thyroid c. Clinically confused with undifferentiated tumors
except: (JIPMER 2014, 2013) d. May present with respiratory distress and dysphagia
a. It arises from ‘C’ cells
b. Secrete high levels of calcitonin
CARCINOMA THYROID
c. It is dependent on TSH
d. Most cases are familial 86. False statement regarding thyroid carcinoma:(PGI Nov 2011)
76. Which of the following does not take radioactive iodine? a. Medullary thyroid carcinoma is associated with MEN-2A
 (Recent Question 2017) b. Follicular carcinoma -Most common type of carcinoma
a. Medullary carcinoma thyroid c. Papillary carcinoma -Multifocal
b. Papillary carcinoma thyroid d. Thyroid lymphoma is often associated with Hashimoto
c. Follicular carcinoma thyroid thyroiditis
d. Hürthle cell carcinoma thyroid e. Anaplastic carcinoma occur in old age women
77. Calcitonin is the marker for: (Recent Question 2017) 87. True about thyroid carcinoma: (PGI Dec 2006)
a. Papillary carcinoma thyroid a. Follicular carcinoma have worse prognosis than papillary
b. Follicular carcinoma thyroid carcinoma
b. Papillary carcinoma spreads by hematogenous route more
Section 1

c. Medullary carcinoma thyroid

d. Anaplastic carcinoma thyroid frequently than follicular carcinoma
c. Papillary carcinoma have increased mortality than
78. Medullary carcinoma thyroid is associated with which mutation?
follicular carcinoma
 (Recent Question 2017)
d. Follicular carcinoma are more bilateral than papillary
a. RET b. MET
carcinoma
c. p53 d. PTEN
e. Follicular carcinoma have more male incidence than
79. RET proto-oncogene is associated with development of: papillary carcinoma
a. Medullary carcinoma thyroid (Recent Question 2018)
88. Low risk in carcinoma thyroid: (PGI Dec 2006)
b. Astrocytoma
a. Men <50 years b. Women <40 years
c. Paraganglioma
c. Papillary carcinoma <4 cm d. Metastasis
d. Hürthle cell tumor thyroid
e. Follicular carcinoma >5c m
 Thyroid 69

89. The most common histologic type of thyroid cancer is: 102. A patient came with a small solitary nodule in right lobe of
 (Recent Question 2015, All India 2008, 2004, thyroid. FNAC shows follicular adenoma. The best surgery

Section 1
 AIIMS Nov 05, PGI Dec 2005) is: (DNB 2002)
a. Medullary type b. Follicular type a. Enucleation b. Sub-total thyroidectomy
c. Papillary type d. Anaplastic type c. Right hemithyroidectomy d. Near-total thyroidectomy
90. Which of the following is not a histological variant of thyroid 103. A 53-year-old female with multinodular goiter underwent
neoplasm?  (All India 2007) radioisotope scan, whose report shows warm nodules. Her
a. Follicular b. Merkel cell chances of warm nodules being malignant is:
c. Insular d. Anaplastic a. 5% b. 10% (MHCET 2016)
c. 15% d. 20%
91. Thyroid carcinoma:
a. Is often associated with hypothyroidism 104. A 45-year-old male presents with 4 × 4 cm, mobile right
b. Often produces hyperthyroidism solitary thyroid nodule of 5 months. The patient is euthyroid.
The following statements about his management are true
c. Is usually euthyroid
except: (AIIMS Nov 2005)
d. Occurs in toxic nodules
a. Cold nodule on thyroid scan is diagnostic of malignancy
92. Amount of I-131 given for carcinoma thyroid: (DPG 2006) b. FNAC is the investigation of choice
a. 5 micro curie b. 50 micro curie c. The patient should undergo hemithyroidectomy if FNAC
c. 5 milli curie d. 50 milli curie report is inconclusive
93. Thyroxine can be given in which thyroid carcinoma: d. Indirect laryngoscopy be done in the preoperative period
 (MCI Sept 2009) to assess mobility of vocal cords
a. Papillary b. Medullary 105. Most common solitary thyroid nodule is:
c. Anaplastic d. Undifferentiated a. Follicular adenoma  (AIIMS Nov 2004, June 93)
94. Thyroid carcinoma causes laryngeal paralysis due to: b. Hurthle cell carcinoma
a. Recurrent laryngeal nerve palsy (PGI June 96) c. Papillary carcinoma d. Solitary idiopathic goiter
b. Vagus nerve palsy 106. What is the most appropriate operation for a solitary nodule
c. Glossopharyngeal nerve palsy in one lobe of thyroid?  (All India 2003, AIIMS Nov 95)
d. Hypoglossal nerve palsy a. Lobectomy b. Hemithyroidectomy
95. Which of the following is used in the treatment of thyroid c. Nodule removal
malignancy? (PGI June 2001) d. Partial lobectomy with 1 cm margin around nodule
a. I-131 b. I-125 107. Which of the following is true about subtotal thyroidectomy?
c. Tc-99 d. P-32 a. Removal of one lobe and isthmus (Recent Question 2018)
e. Strontium b. Removal of both lobes leaving behind 6-8 grams of tissue
96. Which of the following is used in the treatment of well c. Removal of entire lobe with cervical lymph nodes
differentiated thyroid carcinoma: (Recent Question 2013) d. Removal of one lobe with isthmus

Endocrine Surgery
a. I131 b. 99m Tc 108. Percentage of cold nodules that becomes malignant are?
c. 32P d. MIBG a. 5% b. 15% (DNB 2014)
c. 20% d. 40%
109. Which is the investigation of choice to differentiate between
SOLITARY THYROID NODULE benign and malignant thyroid nodule? (DNB 2014)
97. Most sensitive investigation of thyroid nodule: a. USG b. FNAC
a. MRI b. PET Scan (Punjab 2011) c. Scintigraphy d. Biopsy
c. USG d. Clinical examination 110. Management of a single 1 cm non-functioning dominant
nodule of thyroid in an asymptomatic patient:
98. True about solitary thyroid nodule: (PGI Dec 2006)
 (Recent Question 2017)
a. THR-Antibody
a. Observation b. Radioiodine ablation
b. Lined by columnar epithelium
c. Hemithyroidectomy d. Antithyroid drugs
c. Diffuse hyperplasia of thyroid
d. Common in female
e. Thyroidectomy done GOITER
99. A case of solitary thyroid nodule, investigation of choice is: 111. Multi-nodular goiter (MNG) secondary thyrotoxicosis is
 (PGI June 97, 96, AIIMS Nov 97) seen how much percentage of patient with MNG:
a. T3, T4 estimation b. Thyroid scan a. 10% b. 20% (MHSSMCET 2005)
c. FNAC d. Excision biopsy c. 30% d. 40%
100. Initial preferred investigation for thyroid nodule is: 112. The most common presentation of endemic goiter is:
a. FNAC b. Radionucleide test  (All India 96)
c. Thyroid function test d. USG (DPG 2008) a. Hypothyroid b. Diffuse goiter
c. Hyperthyroid d. Solitary nodule
101. Investigation of choice in discrete thyroid swelling is:
113. Thoracic extension of cervical goitre is usually approached
 (Recent Question 2014)
through: (AIIMS May 2005)
a. Isotope scans b. Ultrasonography
a. Neck b. Chest
c. Autoantibody titres d. FNAC
c. Combined cervico-thoracic d. Thoracoscopic
 70 Surgery Essence

114. A 20-year-old girl presents with 9 months history of neck 126. Which of the following is the agent of choice for treating
swelling with thyrotoxic symptoms. On investigation thyrotoxicosis during pregnancy? (COMEDK 2010)
increased T4 and decreased TSH with palpable 2 cm nodule a. Carbimazole b. Propylthiouracil
was found. Next investigation will be: (AIIMS May 2007) c. Methimazole d. Radioactive I-131
a. USG b. Thyroid scan
127. All of the following are features of thyrotoxicosis, except:
c. Radioactive iodine uptake d. CT scan
a. Diastolic murmur (Recent Question 2016)
115. Indication of surgery in a case of thyroid swelling is/are: b. Soft non-ejection systolic murmur
a. Cosmetic b. Pressure symptoms c. Irregularly, irregular pulse
c. Myxedema d. Pain (PGI June 2004)
d. Scratching sound in systole
e. Swelling with symptoms
116. In a patient presenting with a swelling of the thyroid, the 128. Dancing carotid is seen in: (AIIMS Dec 98)
Endocrine Surgery

radionuclide scan showed a cold nodule and the ultrasound a. Thyrotoxicosis b. Hypothyroidism
showed a non cystic solid mass. The management of this c. AV Fistula d. Blow out carotid
patient would be:  (AIIMS June 2002) 129. The best marker to diagnose thyroid related disorder is:
a. Lobectomy b. Hemithyroidectomy a. T3 b. T4
c. Eltroxin d. Radio Iodine therapy c. TSH d. Thyroglobulin
117. Symptoms of endemic goitre are all except: 130. The occurrence of hypothyroidism following administration
a. Cold intolerance b. Hoarseness of supplemental iodine to subjects with endemic iodine to
c. Dysphagia d. Heat intolerance subjects with endemic iodine deficiency goiter is known as:
118. What percentage of cold thyroid nodules are malignant? a. Jod- Basedow effect  (All India 2004)
a. 70–80% b. 50–60% (MHCET 2016) b. Wolff-Chaikoff effect
c. 40–50% d. 10–20% c. Thyrotoxicosis factitia
119. Treatment of choice in cold nodule of thyroid: (JIPMER 93) d. De Quervain’s thyroiditis
a. Subtotal thyroidectomy b. Wait and watch 131. In thyrotoxicosis, β-blockers do not control: (All India 94)
c. I-131 d. Hemithyroidectomy a. Anxiety b. Tremors
120. Which of the following is true?  (AIIMS May 2011) c. Tachycardia d. Oxygen consumption
a. Colloid goiter mostly presents as hyperthyroidism 132. All of the following are associated with thyroid storm,
b. Thyroid storm, the clinical features are primarily due to except:  (All India 2002)
increased thyroxine a. Surgery for thyroiditis
c. Excess calcium intake can lead to hyperthyroidism b. Surgery for thyrotoxicosis
d. Goiter more than 5% of population is endemic goiter c. Stressful illness in thyrotoxicosis
d. I-131 therapy for thyrotoxicosis
121. A 12-year old girl presents with nodular goiter. Which of 133. Cardiovascular findings in an elderly thyrotoxicosis patient
the following statements regarding her evaluation and are all, except: (All India 2000)
management is incorrect? (AIIMS May 2014) a. Early diastolic murmur
a. 99 m-Tc scan should be performed to determine whether b. Systolic ejection murmur
the nodules are hypofunctioning or hyperfunctioning c. Scratch in left 2nd intercostal space
b. Functional thyroid nodules are usually benign d. Irregularly irregular pulse
c. All nodules > 4 cm should be resected irrespective of 134. Treatment of thyroid storm includes all, except:
cytology  (AIIMS Nov 2003)
d. FNAC should be performed for allnodules > 1 cm in a. Propranolol b. Radioactive iodine
diameter c. Hydrocortisone d. Lugol’s iodine
135. Difference between thyrotoxicosis and malignant hyperth-
RETROSTERNAL GOITER ermia is: (AIIMS June 2001)
a. Hyperthermia b. Tachycardia
122. Most common symptom of retrosternal goiter: c. Muscle rigidity d. Elevated serum CPK level
a. Dysphagia b. Stridor (Punjab 2010, PGI June 97) 136. In thyrotoxicosis, which of the following is seen?
c. Dyspnea d. Superior vena cava syndrome a. Pretibial myxedema b. Glycosuria
123. Retrosternal goiter is characterized by: (DPG 2005) c. Unilateral exophthalmos d. All
a. Stridor b. Always malignant 137. Toxic adenoma on scanning appear as: (JIPMER 98)
c. Bilateral d. None of the above a. Hot nodule b. Cold nodule
124. Most commonly used approach for retrosternal goitre: c. Warm nodule d. Neutral
Section 1

a. Transthoracic via second intercostal space 138. Thyroid storm after operation is due to: (COMEDK 2007)
b. Transthoracic via fourth intercostal space a. Inadequate control of hyperthyroidism
c. Trans-sternal through anterior mediastinum b. Massive bleeding
d. Transcervical (Recent Question 2019) c. Recurrent laryngeal nerve injury
d. Postoperative injection
139. A 48-year-old woman underwent subtotal thyroidectomy.
THYROTOXICOSIS
She has vague family history of malignant hyperthermia.
125. Thyroid storm after operation is due to: (COMEDK 2007) She develops agitation, restlessness, fever, tremor, shivering,
a. Inadequate control of hyperthyroidism and tachypnea. Thyrotoxic crises can be best distinguished
b. Massive bleeding from malignant hyperthermia by estimating: (Kerala 2004)
c. Recurrent laryngeal nerve injury a. Temperature variation b. Increased CPK levels
d. Postoperative infection c. LDH d. Muscular rigidity
 Thyroid 71

140. A 55-year-old male patient underwent cholecystectomy for 152. Therapy of choice for diffuse toxic goiter in a patient over
Gall stone calculus. During surgery the patient’s pulse was 45 years:
irregularly irregular, 160/min, BP = 80/50 mm of Hg, temp. a. Surgery b. Antithyroid drugs

Section 1
40°C. On examination a swelling in the neck was found. c. Radioiodine
Most likely diagnosis is: (MAHE 2007) d. Antithyroid drugs first followed by surgery
a. Thyroid storm b. Myocardial infarction
c. Arrythmias d. Stridor 153. Which of the following statements about Grave’s disease is
false? (Recent Question 2018)
141. All of the following conditions are associated with hyper-
a. Results in hyperthyroidism
thyroidism, except: (All India 2011)
a. Hashimoto’s thyroiditis b. Grave’s disease b. Autoimmune disorder
c. Toxic multinodular goiter d. Struma ovary c. Common in male
d. Referred as diffuse toxic goiter
142. Hyperthyroidism occurs in: (PGI Nov 2011)
a. Hashimoto thyroiditis b. Graves’ disease 154. All of the following are true about Graves disease except:
c. Medullary thyroid carcinoma a. Cardiac failure is common (JIPMER 2013)
d. Plummer’s disease b. Hypertrophy and hyperplasia or thyroid gland is due to
e. Struma ovarii TSH-Rab
c. Remissions and exacerbations are not infrequent
143. Which of the following is a symptom of hypothyroidism? d. It is highly vascular with audible bruit
 (JIPMER 2014, 2007)
a. Hyperactivity b. Palpitation
c. Diarrhoea d. Hair loss HYPOTHYROIDISM
144. Reduction of size and vascularity prior to thyroidectomy is 155. In case of hypothyroidism which investigation is most
done by: (Recent Question 2015) informative and most commonly used: (AIIMS June 98)
a. Iodides b. Propylthiouracil a. Serum TSH level b. Serum T3, T4 level
c. Radioiodine d. Propranolol c. Serum calcitonin assay d. Serum TRH assay
145. A patient underwent thyroidectomy for Hyperthyroidism. 156. Hypothyroidism with increased TSH level is seen in all
Two days later he presented with features of thyroid storm. except: (PGI 90)
What is the most likely cause? (AIIMS November 2015) a. Sheehan’s syndrome b. Lithium carbonate therapy
a. Poor antibiotic coverage c. Post radioiodine ablation
b. Rough handling during surgery d. Endemic goitre
c. Removal of parathyroid
d. Inadequate preoperative preparation POST THYROIDECTOMY COMPLICATIONS
146. Treatment of choice for recurrent thyrotoxicosis after
157. During thyroidectomy, inferior thyroid artery is ligated at:
surgery is: (MCI June 2018)
a. Maximally away from the gland (MCI Sept 2005)
a. Further surgery
b. Close to the gland

Endocrine Surgery
b. Radioiodine followed by surgery c. Half way from the gland
c. Radioiodine d. None of the above
d. Observation & follow-up
158. Complications of total thyroidectomy include all except:
 (AIIMS May 2005)
GRAVE’S DISEASE a. Hoarseness b. Airway obstruction
c. Hemorrhage d. Hypercalcemia
147. All of the following are features of Grave’s disease except:
(MCI Sept 2005) 159. Two hours after subtotal thyroidectomy for thyrotoxicosis,
a. More common in males b. Tremor young woman rapidly becomes agitated and complains of
c. Pretibial myxoedema d. Intolerance to heat increasing difficulty in breathing. Her pulse rate rises and
central cyanosis is noticed on examination, her neck is
148. Complications of therapy with radioactive iodine includes:
found to be tensely swollen beneath the stitches. The most
a. Thyroid malignancy b. Hypothyroidism
appropriate management in this case would be: (DPG 2011)
c. Leukemia d. All of the above
a. Intranasal oxygen
149. Which of the following conditions is most common b. Passing an endotracheal tube in the ward
complication of radioiodine treatment of Grave’s disease? c. Removing sutures from all layers in the ward and
 (COMEDK 2005, 2004) evacuation of hematoma
a. Thyroid storm b. Subacute thyroiditis d. Immediate transfer of the patient to the operation theatre
c. Thyroid cancer d. Hypothyroidism for tracheostomy
150. In which of the following conditions radioactive iodine 160. Horner’s syndrome, all are true except: (AIIMS May 2011)
(Irradiation) can be used in Grave’s disease: (PGI Nov 2010) a. Miosis
a. Recurrence b. Anhydrosis
b. Age >40 years c. Hyperchromatic iris
c. Elderly d. Apparent exophthalmos
d. Pregnant 161. Horner’s syndrome is seen in all except:  (AIIMS Nov 2010)
e. Presence of associated co-morbidities a. Carotid artery aneurysm 
151. Pretibial myxedema is seen in: (MHPGMET 2005) b. Medial medullary syndrome
a. Thyrotoxicosis b. Hypothyroidism c. Can occur following surgery for Raynaud’s syndrome
c. Hyperparathyroidism d. All d. Multiple sclerosis
 72 Surgery Essence

162. Horner’s syndrome does not include: (COMEDK 2004) 173. Most dangerous complication in a patient who had
a. Ptosis b. Anhydrosis undergone thyroid surgery and develop hematoma at the
c. Flushing d. Mydriasis operative site: (AIIMS Nov 99)
163. During thyroidectomy, inferior thyroid artery ligation is a. Respiratory obstruction
done at what level? (MHPGMCET 2003) b. Recurrent laryngeal nerve palsy
a. As close to the thyroid gland as possible c. Dysphagia
b. As far away as possible from the thyroid gland d. Shock
c. In the trachea-esophageal groove 174. After thyroidectomy, patient developed stridor within 2
d. Any of the above hours. All are likely cause of stridor except:
164. About thyroid surgery all are true except: (Punjab 2008) a. Hypocalcemia (AIIMS Nov 2001, Nov 2000)
a. Superior thyroid artery is ligated near the gland b. Recurrent laryngeal nerve palsy
Endocrine Surgery

b. Capsule is removed c. Laryngomalacia

c. Inferior thyroid artery is ligated away from gland d. Wound hematoma
d. Capsule is kept intact 175. A 50-year-old male is suffering from severe dyspnea after
165. Hypoparathyroidism following thyroid surgery occurs thyroid surgery, treatment of choice is:  (AIIMS June 97)
within: (AIIMS Nov 2004, Nov 2003) a. Tracheostomy
a. 24 hours b. 2–5 days b. Open the operative site
c. 7–14 days d. 2–3 weeks c. Wait and watch
d. Cricothyroidotomy
166. Complications of hemithyroidectomy include all of the
following except? (All India 2008) 176. A patient operated for thyroid surgery for a thyroid swelling,
a. Hypocalcemia later in the evening developed difficulty in breathing. There
b. Wound hematoma was swelling in the neck. The immediate management
c. Recurrent laryngeal nerve palsy would be: (AIIMS June 2002)
d. External branch of superior laryngeal nerve palsy a. Epinephrine injection
b. Tracheostomy
167. A patient undergoes thyroid surgery, following which he
c. IV calcium gluconate
develops perioral tingling. Blood calcium is 8.9 meq/L. Next
d. Open the wound sutures in the ward
step is: (All India 2001)
a. Vitamin D orally 177. Replacement dose of thyroxine is: (All India 93)
b. Oral calcium and vitamin D a. 0.1–0.2 mg b. 0.3–0.4 mg
c. Intravenous calcium gluconate and serial monitoring c. 1–2 mg d. 3–4 mg
d. Wait for calcium to decrease to < 7.0 before talking further 178. All of the following are early life threatening complications
action of thyroid operation except: (DPG 2010, SGPGI 2005)
168. Patient after thyroid surgery presents with perioral paresthe- a. Tracheomalacia and collapse of the larynx
sia. Serum calcium level is 7 mg/dl. What will be the best b. Wound hematoma with compression of the trachea
management: (AIIMS Nov 2000) c. Hypocalcemia
a. Oral vitamin D3 d. Thyroid storm
b. Oral vitamin D3 with calcium 179. Vocal cord palsy in thyroid surgery is due to injury to:
c. IV calcium gluconate a. Superficial laryngeal nerve  (COMEDK 2008, UPSC 2008)
d. Oral calcium b. Recurrent laryngeal nerve
169. A post-thyroidectomy patient develops signs and symptoms c. Ansa cervicalis d. Vagus nerve
of tetany. The management is: (All India 2000) 180. Hemorrhage after thyroidectomy is due to:
a. IV calcium gluconate b. Bicarbonate  (Recent Question 2014)
c. Calcitonin d. Vitamin D a. External carotid artery b. Internal carotid artery
170. In postoperative room after thyroid surgery patient devel- c. Superior thyroid artery d. Inferior thyroid artery
oped sudden respiratory distress, dressing was removed and
it was found to be slightly blood stained and wound was
bulging. What will be first thing to be done? THYROIDITIS
a. Tracheostomy (AIIMS June 2000, Nov 2000) 181. Thyroid biopsy of a patient showed the presence of Hurthle
b. Cricothyroidotomy cells. Antibodies found in this condition are:  (Punjab 2011)
c. Laryngoscopy and intubation
a. Anti-TPO b. Anti-mitochondrial
d. Remove the stitch and take the patient to O.T.
c. Anti-RNP d. Anti-dsDNA
171. A patient presents with swelling in the neck following a thy-
182. A 40-year-old female presents with fever, fatigue, diffuse
Section 1

roidectomy; what is the most likely resulting complication?

painful swelling in the midline of the neck, FNAC of the
a. Respiratory obstruction  (All India 2001)
same reveals epitheloid cells and giant cells, the likely
b. Recurrent laryngeal nerve palsy
c. Hypovolemia diagnosis is:
d. Hypocalcemia a. Acute thyroiditis b. Subacute thyroiditis
c. Tubercular lymphadenitis d. Hashimotos thyroiditis
172. Patient presents with neck swelling and respiratory distress
few hours after a thyroidectomy surgery. Next management 183. A patient with autoimmune thyroiditis present with hypo-
would be: (All India 2001) thyroidism. Which of the following is true?
a. Open immediately a. Thyroid peroxidase antibodies (JIPMER 2011)
b. Trecheostomy b. Painless enlargement of thyroid
c. Wait and watch c. Common in men
d. Oxygen by mask d. No malignant risk
 Thyroid 73

184. A person has fever and pain in thyroid gland. True 197. The only reason for operating in case thyroiditis:
statement(s) is/are: (PGI June 2009) a. To prevent cancerous degeneration
a. T3 and T4 level normal b. ↑ESR

Section 1
b. For relief of pain in neck and ear
c. ↑TSH d. It is due to TB c. To overcome pressure on trachea or esophagus
e. Radioactive iodine uptake is ↑ed d. To cure the toxic reaction
185. Hashimoto’s thyroiditis, all are true except: (AIIMS May 2011) e. If there is auto immune reaction
a. Follicular destruction b. Increase in lymphocytes 198. All are true abut Hashimoto’s thyroiditis except: (Kerala 95)
c. Oncocytic metaplasia d. Orphan Annie eye nuclei
a. Antithyroid microsomal antibodies
186. The laboratory investigation of a patient shows ↓T4, and b. Antithyroid nuclear antibodies
↑TSH. Which of the following is the most likely diagnosis: c. Anti-TSH receptor antibodies
 (All India 2011) d. Increased level of thyroid hormones
a. Grave’s disease b. Hashimoto’s disease
c. Pituitary failure d. Hypothalamic failure 199. The thyroiditis also known as “Painless Thyroiditis”:
a. Subacute lymphocytic thyroiditis (MAHE 2007)
187. Which of the following conditions is associated with
b. de-Quervain’s thyroiditis
hypothyroidism? (All India 2011)
a. Hashimoto’s thyroiditis b. Grave’s disease c. Hashimoto’s thyroiditis
c. Toxic multinodular goiter d. Struma ovary d. Riedel’s thyroiditis
188. Most common cause of thyroiditis is:  (All India 2000) 200. A patient present with bilateral proptosis, heat intolerance
a. Reidel’s thyroiditis b. Subacute thyroiditis and palpitations; most unlikely diagnosis here would be:
c. Hashimoto’s thyroiditis d. Viral thyroiditis (All India 2001, 2000)
189. All of the following are true of de-Quervain’s thyroiditis a. Hashimoto’s thyroiditis b. Thyroid adenoma
except: (All India 1996) c. Diffuse thyroid goiter d. Reidel’s thyroiditis
a. Pain 201. DeQvervain’s thyroiditis is characterised by:
b. Increased ESR a. Mononuclear cell infiltration (COMEDK 2014)
c. Increased radioactive iodine uptake b. Histiocyte reaction
d. Fever
c. Giant cell infiltration d. Eosinophilia
190. Not a feature of de-Quervain’s disease: (All India 2002)
a. Autoimmune in etiology
b. ↑ ESR THYROGLOSSAL CYST AND FISTULA
c. Tends to regress spontaneously 202. Hyoid bone is closely associated with: (Orissa 2011)
d. Painful and associated with enlargement of thyroid a. Bronchogenic cyst b. Cystic hygroma
191. Which of the following is wrong about subacute thyroiditis? c. Branchial cyst d. Thyroglossal cyst/fistula
a. Usually presents with painful enlargement of thyroid
203. True about thyroglossal cyst is all except:
gland (Orissa 2011)
a. Does not move with deglutition (MHPGMCET 2003)

Endocrine Surgery
b. There may be features of hyperthyroidism or hypothy-
roidism b. Move with protrusion of tongue
c. In the thyrotoxic phase radioiodine uptake is increased c. Sistrunk’s operation is treatment of choice
d. High ESR d. Most common site is subhyoid region
192. ‘Hurthle cells ‘ are seen in: (All India 95) 204. A 10-year-old child presented with midline swelling in
a. Agranulomatous thyroiditis anterior position of neck. Most probable diagnosis is:
b. Hashimoto’s thyroiditis a. Thyroglossal cyst b. Thyroglossal fistula
c. Papillary carcinoma of the thyroid c. Cold abscess d. Acute lymphadenitis
d. Thyroglossal cyst
193. A patient presents with bilateral proptosis, heat intolerance
and palpitations. Most unlikely diagnosis here would be:
 (All India 2001)
a. Hashimoto’s thyroiditis b. Thyroid adenoma
c. Diffuse thyroid goitre d. Reidel’s thyroiditis
194. A 25-years-old male presents with ophthalmologic signs of
thyrotoxicosis. All are possibilities, except: (All India 2002)
a. Diffused thyroid goitre b. Hashimoto’s thyroiditis
c. Riedel’s thyroiditis d. Adenomatous goitre
195. A young patient has a midline, tender swelling in neck
occurring after an attack of sore throat. The diagnosis is: 205. Sistrunk’s operation is done in:
 (AIIMS Nov 93)  (WBPG 2015, MHPGMCET 2008, 2006)
a. Acute thyroiditis b. Thyroglossal cyst a. Parotid tumor b. Thyroglossal fistula
c. Subacute thyroiditis d. Toxic goiter c. Thyroglossal cyst d. Branchial fistula
196. In Hashimoto’s disease serum antibodies are mainly against: 206. Most common site of thyroglossal cyst:(Recent Question 2013,
 (Recent Question 2016) DNB 2009, 2007, 2005, 2003, MHSSMCET 2005, AIIMS June 97)
a. Thyroid follicles b. Thyroxine a. Suprahyoid b. Hyoid
c. Thyroglobulins d. Iodine c. Subhyoid d. Intra-thyroid
 74 Surgery Essence

207. The following statements about thyroglossal cyst are true, MISCELLANEOUS
except: (All India 2006)
a. Frequent cause of anterior midline neck masses in the first 218. Scabard trachea is seen in: (Karnataka 99)
decade of life a. Thyroid cancer b. Thyroiditis
b. The cyst is located within 2 cm of the midline c. Goitre d. All of the above
c. Incision and drainage is the treatment of choice 219. A new born with a goiter large enough to cause dyspnoea is
d. The swelling moves upwards on protrusion of tongue best treated with:
208. Thyroglossal cyst may occasionally give rise to carcinoma: a. Sulfonamides b. Tracheostomy
a. Papillary b. Medullary c. T3 d. Iodides
c. Anaplastic c. Follicular 220. Which of the following factors contribute to the development
Endocrine Surgery

209. Sistrunk’s operation consists of: (DPG 2009 March) of duodenal ulcer? (PGI 2001)
a. Excision of hyoid bone and cone of tongue muscle a. I-131 b. I-125
b. Excision of hyoid bone and the cyst c. Tc-99 d. P-32
c. Excision of central part of hyoid bone and cone of tongue 221. In pregnancy: (APPG 2004)
muscles upto foramen caecum a. Radioiodine contraindicated
d. Excision of cyst only b. Thiouracil is contraindicated
210. A central midline neck swelling is noted in a 4 years old girl c. Surgery is contraindicated
posted for tonsillectomy. The swelling is, painless, mobile, d. None
and cystic, just below the hyoid bone of size 2x1.1x1cm. USG 222. Pendred’s syndrome is due to a defect in:
showed a thick walled cystic lesion. Management would (MCI June 2018, COMEDK 2007, 2008)
include: (AIIMS Nov 97) a. Chromosome 7p b. Chromosome 7q
a. Surgical removal b. Antibiotics c. Chromosome 8p d. Chromosome 8q
c. Percutaneous aspiration d. Chest X-ray
223. Reddish swelling in the region of foramen caecum:
(DPG 2007)
THYROID ANATOMY AND PHYSIOLOGY
a. Lingual thyroid b. Lingual tonsil
211. The occurence of hyperthyroidism following administration c. Ranula d. Thyroglossal cyst
of supplemental iodine to subject with endemic iodine 224. True about Struma Ovarii: (PGI June 2007)
deficiency goitre is known as:  (All India 2012)
a. Ectopic thyroid
a. Jod-Basedow effect b. Wolff-Chaikoff effect
b. Ectopic ovary
c. Thyrotoxicosis factitia d. De-Quervains thyroiditis
c. Malignancy
212. Which of the following most closely represents the lowest
d. Benign lesion
detection limit for third generation TSH assays?
e. Included in teratoma
a. 0.4 mIU/L b. 0.04 mIU/L (All India 2012)
c. 0.004 mIU/L d. 0.0004 mIU/L 225. Absent parathyroid, thymic aplasia with immuno-deficiency
213. Recurrent laryngeal nerve is in close association with: and cardiac defects are features of: (MHPGMCET 2009)
 (AIIMS Nov 93) a. Autoimmune polyglandular syndrome
a. Superior thyroid artery b. Inferior thyroid artery b. Pendred syndrome
c. Middle thyroid vein d. Superior thyroid vein c. Di George syndrome
214. Normal thyroid weight varies …….. with dietary iodine d. Lesch-Nyhan syndrome
content: 226. This picture depicts …….. of examination of the thyroid
a. Directly proportional b. Inversely gland. Choose the correct answer: (APPG 2016)
c. Inverse cubically d. Not fixed a. Kocher’s method
215. Average weight of thyroid gland where diet is rich in iodine b. Lahey’s method
is: c. Crile’s method
a. 10–12 gm b. 14–16 gm d. Pizzillo’s method
c. 18–20 gm d. 28–30 gm
216. Protein bound iodine measures secretary function of thyroid
in all of the following circumstances except: (All India 90)
a. Nephrotic syndrome
b. Following hemithyroidectomy
Section 1

c. During ampicillin therapy

d. Asthamatics on ephedrine
217. Isthmus of thyroid gland overlies the: (DPG 97)
a. 1st tracheal cartilage
b. 1st and 2nd tracheal cartilage
c. 2nd and 3rd and 4th tracheal cartilage
d. 3rd and 4th tracheal cartilage
 Explanations

PAPILLARY CARCINOMA
1. Ans. b. Malignant goiter (Ref: Schwartz 10/e p1542-1544; Sabiston 20/e p902; Bailey 27/e p818; Harrison 20/e p2715, 19/e p2305)
2. Ans. d. Papillary carcinoma
3. Ans. a. ‘Orphan-Annie eye’ nucleus cells
4. Ans. a. Total thyroidectomy with lymph nodal dissection of the same side
5. Ans. c. Lymph node metastases is common; d. Can metastasize to lung; e. Multiple foci of tumour is seen

Papillary carcinoma are rarely encapsulatedQ

6. Ans. c. Columnar d. Insular; e. Diffuse sclerosing (Ref: Schwartz 10/e p1542, 9/e p1361-1363; Sabiston 20/e p902, 19/e p906-909; Bailey 27/e
p818, 26/e p765, 25/e p793-796)

Types of Papillary Carcinoma Associated with Poor Prognosis

1. Tall cellQ 5. Clear cellQ
2. InsularQ 6. TrabecularQ
3. ColumnarQ 7. Poorly differentiated type
4. Diffuse sclerosingQ
7. Ans. b. Total thyroidectomy with left sided modified neck dissection
8. Ans. a. Follicular carcinoma of thyroid (Ref: Schwartz 10/e p1542; Sabiston 20/e p902; Bailey 27/e p818)

Psammoma Bodies (PSM)

1. Papillary carcinoma thyroidQ 2. Papillary carcinoma (RCC) Q
3. Serous cystadenomaQ 4. MeningiomaQ
9. Ans. a. FNAC easy; c. Psammoma body; d. Spread to cervical LN
10. Ans. a. Radiation is a risk factor; b. Multifocal; d. Distant metastasis is seen
11. Ans. d. Papillary carcinoma 12. Ans. b. Papillary
13. Ans. a. Start thyroxine suppression therapy (Ref: Schwartz 10/e p1549; Sabiston 20/e p906; Bailey 27/e p819)

Well Differentiated Thyroid Cancer

1. Papillary carcinoma of thyroid Q
2. Follicular carcinoma of thyroidQ
3. Follicular variant of papillary carcinoma thyroidQ 4. Hurthle cell carcinoma (variant of follicular carcinoma thyroid) Q

Postoperative Management of Well-differentiated Thyroid Cancer

Radioiodine Therapy
• Postoperative RAI therapy reduces recurrence and provides a small improvement in survival, even in low-risk patientsQ.
• Metastatic differentiated thyroid carcinoma can be detected and treated by 131I in about 75% of patientsQ.
• RAI effectively treats >70% of lung micrometastasesQ that are detected by RAI scan in the presence of a normal chest x-ray,
whereas the success rates drop to <10% with pulmonary macrometastases. Early detection therefore appears to be very important
to improve prognosis.

RAI Ablation Currently is Recommended for

• All patients with stage III or IV diseaseQ
• All patients with stage II disease <45 yearsQ
• Most patients 45 years or older with stage II diseaseQ
• Patients with stage I disease who have aggressive histologies, nodal
metastases, multifocal disease, and extrathyroid or vascular invasionQ

• T4 therapy should be discontinued for 6 weeks before scanning with 131I. Patients should receive T3 during this time period
to decrease the period if hypothyroidism. T3 has a shorter half-life than T4 (1 day vs. 1 week) and needs to be discontinued for
2 weeks to allow TSH levels to rise before treatmentQ.

 76 Surgery Essence

• A low-iodine diet also is recommended during this 2-week periodQ.

• The usual protocol involves administering a screening dose of 1 to 3 mCi of 123I and measuring uptake 24 hours later. After a
total thyroidectomy, this value should be <1%. A “hot” spot in the neck after initial screening usually represents residual normal
tissue in the thyroid bed.
• If there is significant uptake, then a therapeutic dose of 131I, 30 to 100 mCiQ should be administered to low-risk patients and 100
to 200 mCi in high-risk patientsQ.
• Approximately one third of these patients demonstrate uptake on posttreatment imaging, and Tg levels usually decrease in these
patients, documenting therapeutic benefitQ.
• Patients with previously positive scans and patients with serum Tg levels >2 ng/mLQ usually need another 131I treatment after
6 to 12 months until one or two negative scans are obtained.
Endocrine Surgery

• The follow-up scan can be done after hormone withdrawal or after recombinant TSH. The latter is more expensiveQ but is
preferred by patients.
External Beam Radiotherapy and Chemotherapy
• EBRT is occasionally required to control unresectable, locally invasive or recurrent disease and to treat metastases in support
bonesQ to decrease the risk of fractures.
• EBRT is of value for the treatment and control of pain from bony metastasesQ when there is minimal or no RAIUQ.
• Single and multidrug chemotherapy has been used with little successQ in disseminated thyroid cancer, and there is no role for
routine chemotherapy
• Doxorubicin (Adriamycin) and paclitaxel (Taxol) are the most frequently used agents.
Thyroid Hormone
• T4 is necessary as replacement therapyQ in patients after total or near-total thyroidectomy
• Has the additional effect of suppressing TSHQ and reducing the growth stimulusQ for any possible residual thyroid cancer
cellsQ.
• TSH suppression reduces tumor recurrence ratesQ.
• T4 should be administered to ensure that the patient remains euthyroidQ, with circulating TSH levels at about 0.1 U/L in low-risk
patients, or <0.1 U/mL in high-risk patients.

14. Ans. a. Papillary carcinoma of thyroid 15. Ans. b. Mucinous cystadenoma of ovary
16. Ans. c. Near total thyroidectomy with modified neck dissection
17. Ans. c. Excellent prognosis 18. Ans. a. Papillary carcinoma
19. Ans. b. Bilaterality; c. Local recurrence common; d. Increased lymph node metastasis (Ref: Schwartz 10/e p1542-1545; Sabiston 20/e
p902, 904)
Papillary Follicular
Male incidence + ++Q
Lymph node metastasis +++Q +
Blood vessel invasion + +++Q
Recurrence rate + ++Q
Overall mortality + ++Q
Location of recurrent carcinoma
Distant metastasis + ++
Nodal metastasis +++ Q
+
Local recurrence ++Q +
Bilaterality +++Q +
Section 1

20. Ans. c. Papillary carcinoma 21. Ans. a. Papillary carcinoma

22. Ans b. Metastatic foci from primary in thyroid (Schwartz 10/e p1542; Sabiston 20/e p903)

Lateral Aberrant Thyroid

• Any thyroid tissue found laterally separate from the thyroid gland, is always considered to be a metastasis in a cervical lymph
nodeQ, as aberrant thyroid tissue never occurs in lateral position.
• Aberrant thyroid tissues are found along the course of the thyroglossal tract:
− LingualQ − CervicalQ − ThoracicQ
• Papillary carcinoma of thyroid is MC associatedQ with lateral aberrant thyroid
 Thyroid 77

23. Ans. a. I-131

24. Ans. b. Beta rays (Schwartz 10/e p1546; Sabiston 20/e p908; William’s Endocrinology 10/e p479)

Section 1
25. Ans. d. Lateral aberrant thyroid
26. Ans. d. Bony metastasis in early stage (Ref: Schwartz 9/e p1362, 1363, 1367, 1368; Sabiston 20/e p902, 904, 909, 910; Bailey 27/e p818)
27. Ans. b. Papillary
28. Ans. d. >60% (Ref: Schwartz 10/e p1542; Sabiston 20/e p904)
29. Ans. a. Papillary carcinoma thyroid (Ref: Schwartz 10/e p1542; Sabiston 20/e p903)
30. Ans. a. Papillary carcinoma thyroid (Ref: Schwartz 10/e p1542; Sabiston 20/e p903)
31. Ans. c. Radioactive iodine ablation (Ref: Schwartz 10/e p1546; Sabiston 20/e p906; Bailey 27/e p819)

FOLLICULAR CARCINOMA
32. Ans. d. Diagnosis by FNAC (Fef: Schwartz 10/e p1544, 1357; Sabiston 20/e p906; Bailey 27/e p818)

Limitations of FNAC in Thyroid Diseases

1. Not able to distinguish follicular adenoma from follicular carcinomaQ

2. Not able to distinguish Hurthle cell adenoma from Hurthle cell carcinomaQ
3. Useless in Reidel’s thyroiditisQ (Biopsy is preferred)Q
4. FNAC is less reliable in patients who have history of head and neck irradiation or family history of thyroid cancer due to higher
likelihood of multifocal lesions and occult cancerQ

33. Ans. a. Follicular

34. Ans. a. RAS (Ref: Schwartz 10/e p1541; Sabiston 20/e p901)
• Genes implicated in FCT: p53Q, PTENQ, RasQ , PAX8/PPAR1

Oncogenes and Tumor-Suppressor Genes Implicated in Thyroid Tumorigenesis

Gene Function Tumor
Oncogenes

Endocrine Surgery
RETQ Membrane receptor with tyrosine kinase activity Sporadic and familial MTC, PTC (RET/PTC
rearrangements)
METQ Same Overexpressed in PTC
TRK1 Same Activated in some PTC
TSH-R Linked to heterotrimeric G protein Hyperfunctioning adenoma
Gs (gsp) Signal transduction molecule (GTP binding) Hyperfunctioning adenoma, follicular adenoma
RasQ Signal transduction protein Follicular adenoma and carcinoma, PTC
PAX8/PPAR1 Oncoprotein Follicular adenoma, follicular carcinoma
B-Raf (BRAF)Q Signal transduction PTC, tall cell and poorly differentiated, anaplastic
Tumor suppressors
p53Q Cell cycle regulator, arrests cells in G1, induces De-differentiated PTC, FTC, anaplastic cancers
apoptosis
p16Q Cell cycle regulator, inhibits cyclin dependent Thyroid cancer cell lines
kinase
PTENQ Protein tyrosine phosphatase Follicular adenoma and carcinoma

35. Ans. c. Vascular invasion (Ref: Schwartz 10/e p1544; Sabiston 20/e p904; Bailey 27/e p818; Harrison 20/e p2715, 19/e p2305)
36. Ans. b. Follicular 37. Ans. a. Follicular carcinoma
38. Ans. a. Follicular 39. Ans. d. Cold nodules are diagnostic of malignancy
40. Ans. b. Follicular carcinoma 41. Ans. a. Follicular; c. Medullary
42. Ans. c. Follicular CA Thyroid 43. Ans. d. Follicular carcinoma of thyroid
 78 Surgery Essence

44. Ans. b. Follicular carcinoma thyroid (Ref: Schwartz 10/e p1546; Sabiston 20/e p910)
45. Ans. a. Radioiodine 46. Ans. a. Hematogenous spread
47. Ans. c. Capsular invasion 48. Ans. a. Follicular carcinoma

MEDULLARY CARCINOMA
49. Ans. a. Serum calcitonin (Ref: Schwartz 10/e p1549-1550; Sabiston 20/e p909; Bailey 27/e p820; Harrison 20/e p2716, 19/e p2307)
50. Ans. c. Surgery only (Ref: Schwartz 10/e p1550; Sabiston 20/e p909; Bailey 27/e p820)
51. Ans. d. Take up radioiodine
Endocrine Surgery

• I131 scan is of no use as MTC is TSH independentQ, so MTC does not take up radioiodine (I131).
52. Ans. c. Anaplastic carcinoma, e. Medullary carcinoma
• Radioactive iodine is used to destroy residual thyroid tissue (thyroid ablation) in well differentiated thyroid cancer.
53. Ans. d. 6 months (Ref: Schwartz 9/e p1368; Sabiston 20/e p909)

Prophylactic Thyroidectomy in RET Mutation Carriers

MEN-2A Before 5 yearsQ
MEN-2B Before 1 yearQ
• Central neck dissection is avoided in childrenQ.
• Indications of central neck dissection in children:
1. Raised calcitoninQ 2. USG suggesting thyroid cancerQ >5 mm 3. Evidence of LN metastasis

54. Ans. a. 5 years

55. Ans. None (Ref: Sabiston 20/e p909)

• Sabiston says “The calcitonin excess in MTC is not associated with hypocalcemia.”Q
• Robbins says “Notably hypocalcemia is not a prominent feature despite the presence of raised calcitonin levels.”Q

56. Ans. a. Parafollicular cells 57. Ans. a. Calcitonin (Ref: Schwartz 10/e p1549; Sabiston 20/e p909; Bailey 27/e p820)
58. c. Surgery only 59. Ans. a. Medullary carcinoma thyroid
60. Ans. b. Calcitonin 61. Ans. c. CEA 62. Ans. c. Ret proto-oncogene
63. Ans. c. Total thyroidectomy and modified neck dissection on the side of enlarged lymph node
64. Ans. b. Medullary carcinoma 65. Ans. b. Medullary carcinoma
66. Ans. b. Medullary 67. Ans. b. Medullary
68. Ans. c. Medullary carcinoma 69. Ans. a. Total thyroidectomy
70. Ans. d. Histological mitochondria is essential for diagnosis
71. Ans. a. Ret proto-oncogene 72. Ans. a. Diarrhea 73. Ans. b. Arises from parafollicular C cells
74. Ans. c. Increased calcitonin is not associated with hypocalcemia
75. Ans. c. It is dependent on TSH
76. Ans. a. Medullary carcinoma thyroid (Ref: Schwartz 10/e p1550; Sabiston 20/e p909; Bailey 27/e p820)
77. Ans. c. Medullary carcinoma thyroid (Ref: Schwartz 10/e p1550; Sabiston 20/e p909; Bailey 27/e p820)
78. Ans. a. RET (Ref: Schwartz 10/e p1541; Sabiston 20/e p909)
79. Ans. a. Medullary carcinoma thyroid (Ref: Schwartz 10/e p1541; Sabiston 20/e p909)
Section 1

ANAPLASTIC CARCINOMA
80. Ans. c. Long term survival in patient undergoing surgery; e. Highly chemosensitive (Ref: Schwartz 10/e p1551, Sabiston 20/e p910)
81. Ans. d. Anaplastic carcinoma
82. Ans. d. Palliative/Symptomatic treatment
83. Ans. d. Anaplastic

THYROID METASTASIS
84. Ans. c. Breast (Schwartz 10/e p1551)
 Thyroid 79

Metastatic Tumors of Thyroid

Section 1
• Rare, most cases are found in autopsy
• MC site of primary: CA BreastQ > CA Lung
• If thyroid metastases is detected pre-mortem, MC site of primary: RCCQ >CA Breast > CA Lung

THYROID LYMPHOMA
85. Ans. b. Slow growing (Ref: Schwartz 10/e p1551; Sabiston 20/e p910; Bailey 27/e p821; Harrison 19/e p2307)

• Lymphomas of the thyroid gland are rapidly growing tumors and usually present with goiter that has grown significantly over
a short period.

CARCINOMA THYROID
86. Ans. b. Follicular carcinoma—Most common type of carcinoma (Ref: Schwartz 9/e p1361; Sabiston 20/e p900; Bailey 27/e p818)
87. Ans. a. Follicular carcinoma have worse prognosis than papillary carcinoma; e. Follicular carcinoma have more male incidence than
papillary carcinoma
88. Ans. b. Women <40 years; c. Papillary carcinoma <4 cm (Ref: Schwartz 9/e p1362-1363; Sabiston 20/e p903; Bailey 27/e p818)
Prognostic Risk Classification for Well Differentiated Thyroid Cancer (AMES or AGES)
Features Low Risk High Risk
Age <40 years
Q
>40 years
Metastasis None Regional or distantQ
Size <4 cmQ >4 cm
Grade Well differentiated Poorly differentiatedQ
Extent No local extension, intrathyroidal, no capsular invasion Capsular invasion, extrathyroidal extensionQ

Prognostic Indicators of Differentiated Thyroid cancer (PTC, FTC)

Endocrine Surgery
AGES Scoring SystemQ
• Age, histologic Grade, Extrathyroidal invasion, and metastases and tumor Size to predict the risk of dying from papillary cancer.
• Low-risk patients are young, with well-differentiated tumors, no metastases, and small primary lesions
• High-risk patients are older, with poorly differentiated tumors, local invasion, distant metastases, and large primary lesions.
The MACIS ScaleQ
• This scale incorporates distant Metastases, Age at presentation (<40 or >40 years old), Completeness of original surgical resection,
extrathyroidal Invasion, and Size of original lesion.
AMES SystemQ
• To classify differentiated thyroid tumors into low- and high-risk groups using Age (men <40 years old, women <50 years old),
Metastases, Extrathyroidal spread, and Size of tumors (<5 or >5 cm).

89. Ans. c. Papillary type 90. Ans. b. Merkel cell 91. Ans. c. Is usually euthyroid
92. Ans. d. 50 milli curie (Schwartz 9/e p1365-1366; Sabiston 20/e p908; Bailey 25/e p797; Harrison 20/e p2716, 19/e p2306)

• Amount of I131 given for carcinoma thyroid is 50 milli curie (30-100 mCi).
• Schwartz says “If there is significant uptake, then a therapeutic dose of 131
I, 30 to 100 mCi should be administered to low-risk
patients and 100 to 200 mCi in high-risk patients.”

93. Ans. a. Papillary 94. Ans. a. Recurrent laryngeal nerve palsy

• The nerves found in close relationship to thyroid gland and therefore likely to be involved in malignant spread and thyroid
surgery are recurrent laryngeal nerve and superior laryngeal nerve.

95. Ans. a. I-131 (Ref: Schwartz 10/e p1546; Sabiston 20/e p908; Bailey 27/e p819; Harrison 20/e p2716, 19/e p2306; William’s Endocrinology 10/e p479)
96. Ans. a. I131
 80 Surgery Essence

SOLITARY THYROID NODULE`

97. Ans. c. USG (Ref: Schwartz 10/e p1540; Sabiston 20/e p895)

• PET scans are not routinely used in the evaluation of thyroid nodules, however, they may show clinically occult thyroid lesions.
• Emedicine-Medscape says “USG is the most sensitive method for diagnosing intrathyroid lesions”
• CT and MRI are neither specific nor sensitive in diagnosing the intrathyroid lesions.

Ultrasound in STN
• Ultrasound is helpful in assessing a thyroid nodule.
Endocrine Surgery

• Advantages: Portability, cost-effectiveness, and lack of ionizing radiation.

• It is extremely useful in patients who are being managed conservativelyQ because it can easily determine whether a nodule has
increased in size.
• Ultrasound is used routinelyQ in the office setting and is also available for intraoperative evaluation.
• It has proved highly effective in determining the location and characteristics (cystic versus solid) Q of nodules but is unable to
accurately predict the diagnosis of solid nodules.

Ultrasound features of carcinoma in a Thyroid Nodule

Feature Carcinoma/Malignancy
Structure Hypoechoic/ Nonhomogeneous/ SolidQ
Regressive changes Rare
Microcalcifications CommonQ
Peripheral rim Variable
Internal vascularity CommonQ (70-100 percent)
Lymph nodes Relatively commonQ

98. Ans. d. Common in female; e. Thyroidectomy done (Ref: Schwartz 10/e p1537-1539; Harrison 20/e p2711, 19/e p2303)

Solitary Thyroid Nodule

• Palpable discrete swelling within an otherwise apparently normal thyroid gland.
• Incidence in adults is 1–10%.
• STN are 4 times more common in womenQ than in men.
• There is nodular hyperplasiaQ (not the diffuse hyperplasia)
• THR-Ab is not found in STN.
• STN are more likely to be neoplastic than multiple nodules.
• Nodules in younger patients are more likely to be neoplasticQ than those in older patients.
• History of radiation exposure increases the risk of malignancyQ.
• Cold nodules (don’t take up radioactive iodine) are more likely to be malignant (15–20%)Q than hot (take up radioactive iodine)
nodules (1–3%)Q
• STN are removed surgicallyQ to exclude malignancy.

99. Ans. c. FNAC (Ref: Schwartz 10/e p1538; Sabiston 20/e p897)

• FNAC is the investigation of choice in discrete thyroid swellings, offers excellent patient compliance and is easy and quick to
performQ.
• FNAC cannot distinguish between benign follicular adenoma and follicular carcinomaQ.

100. Ans. c. Thyroid function test (Ref: Sabiston 20/e p890; Harrison 20/e p2711, 19/e p2303)
Section 1

• Initial investigation done in STN is thyroid function test (TFT) Q.

• Investigation of choice in STN for diagnosis is FNACQ.

Solitary Thyroid Nodule

• Initial investigation done in STN is thyroid function test (TFT) Q.
• If TFT is raised, next investigation is thyroid scan, (For hot nodules, RAI ablation or surgery is done; For warm or cold nodules,
follow-up or surgery) Q
• If TFT is normal, USG is done (Aspiration in cystic lesions, FNAC for solid or heterogenous lesions) Q.
• Investigation of choice in STN for diagnosis is FNACQ.
 Thyroid 81

101. Ans. d. FNAC 102. Ans. c. Right hemithyroidectomy 103. Ans. a. 5%

104. Ans. a. Cold nodule on thyroid scan is diagnostic of malignancy (Ref: Schwartz 10/e p1537; Sabiston 20/e p890; Chandrasoma Taylor 3/e

Section 1
p849-850; Harrison 20/e p2711, 19/e p2303)
105. Ans. a. Follicular adenoma

• MC STN is colloid goiter > follicular adenoma.

106. Ans. b. Hemithyroidectomy (Ref: Schwartz 10/e p1540; Harrison 20/e p2711, 19/e p2303)

Hemithyroidectomy
• Hemithyroidectomy is removal of one lobe with isthmus.
• Hemithyroidectomy is treatment of choice for follicular adenoma and solitary thyroid nodule.

107. Ans. b. Removal of both lobes leaving behind 6-8 grams of tissue (Ref: Sabiston 20/e p906; Bailey 27/e p814; Schwartz 10/e p1551)

Surgery Structure Removed

Hemithyroidectomy (Thyroid lobectomy) Removal of one lobe with isthmusQ
Subtotal thyroidectomy Removal of both lobes leaving behind 3-4 gms of tissue in each lobeQ
Near-total thyroidectomy Leaving <1 gm of tissue adjacent to RLN at ligament of Berry on one sideQ
Total thyroidectomy Removal of all visible thyroid tissueQ
Hartley-Dunhill procedure Removal of one lobe with isthmus & second lobe partially (leaving 4-6 gms of
thyroid tissue)Q
108. Ans. c. 20% (Ref: Bailey 27/e p804)

• About 80% of discrete swellings are cold. The risk of malignancy is higher in “cold” lesions (20%) compared to “hot” or
“warm” lesions (< 5%).

109. Ans. b. FNAC 110. Ans. a. Observation (Ref: Schwartz 10/e p1540; Sabiston 20/e p890; Bailey 27/e p810)

GOITER
111. Ans. c. 30% (Ref: Bailey 27/e p807)

Endocrine Surgery
Complications of Multi-nodular Goiter

• Secondary Thyrotoxicosis: Transient episodes of mild hyperthyroidism are common, occurring in up to 30%Q of patients.
• Carcinoma: An increased incidence of cancer (usually follicular) has been reported from endemic areasQ.

112. Ans. b. Diffuse goiter (Ref: Harrison 20/e p2711, 19/e p2301)

Endemic Goiter

• Worldwide, diffuse goiter is most commonly caused by iodine deficiency and is termed endemic goiter when it affects >5%Q of
the population.
• Endemic goiter occurs in geographical areas where the soil, water and food supply contains low levels of iodineQ.
• The lack of iodine leads to decreased synthesis of thyroid hormones and a compensatory increase in TSH which in turn leads to
follicular cell hypertrophy and hyperplasia and goitrous enlargement leading to diffuse hyperplastic goiterQ.
• Mostly, patients are euthyroidQ.

113. Ans. a. Neck (Ref: Schwartz 10/e p1554)

• Virtually all intrathoracic goiters can be removed via a cervical incisionQ.
114. Ans. b. Thyroid scan (Ref: Sabiston 20/e p897; Schwartz 10/e p1537)
115. Ans. a. Cosmetic; b. Pressure symptoms; e. Swelling with symptoms (Ref: Schwartz 9/e p1358; Sabiston 20/e p899)

Indications of Surgery in Thyroid Swelling

1. Neoplasia (FNAC positive, clinical suspicion) Q 3. Pressure symptomsQ

2. Toxic adenomaQ 4. Cosmetic reason or patient’s preferenceQ
 82 Surgery Essence

116. Ans. b. Hemithyroidectomy 117. Ans. None 118. Ans. d. 10–20%

• Cold nodules (don’t take up radioactive iodine) are more likely to be malignant (15–20%)Q than hot (take up radioactive iodine)
nodules (1–3%)Q

119. Ans. d Hemithyroidectomy

120. Ans. d. Goiter more than 5% of population is endemic goitre (Ref: Harrison 19/e p2301, 18/e p2931)
121. Ans. c. All nodules > 4 cm should be resected irrespective of cytology (Ref: Schwartz 9/e p1358; Sabiston 20/e p895-899, 19/e p899; Harrison
20/e p2711, 19/e p2301)
All nodules > 4 cm should be resected irrespective of cytology, is an incorrect statement.
Endocrine Surgery

RETROSTERNAL GOITER
122. Ans. c. Dyspnea (Ref: Schwartz 10/e p1537; Sabiston 20/e p893-894; Bailey 27/e p810)
123. Ans. a. Stridor
124. Ans. d. Transcervical (Ref: Schwartz 10/e p1537; Sabiston 20/e p894; Bailey 27/e p810)

THYROTOXICOSIS
125. Ans. a. Inadequate control of hyperthyroidism (Ref: Schwartz 10/e p1534; Sabiston 20/e p920; Bailey 27/e p811, 758; Harrison 20/e p2712,
19/e p2297)
126. Ans. a. Carbimazole (Ref: Harrison 20/e p2706) 127. Ans. a. Diastolic murmur (Ref: Harrison 20/e p2704, 19/e p2294)
128. Ans. a. Thyrotoxicosis (Ref: Harrison 20/e p2704, 19/e p2294)

Dancing Carotids may be seen in

• Aortic regurgitationQ • ThyrotoxicosisQ

129. Ans. c. TSH (Ref: Schwartz 10/e p1529; Sabiston 20/e p895; Bailey 27/e p/802; Harrison 20/e p2697, 19/e p2288)

The ultrasensitive TSH assay has become the most sensitive and specific test for the diagnosis of hyper- and hypothyroidism
and for optimizing T4 therapyQ.

The enhanced sensitivity and specificity of TSH assays have greatly improved laboratory assessment of thyroid functionQ.

130. Ans. b. Wolff-Chaikoff effect (Ref: Schwartz 10/e p1526; Sabiston 20/e p886; Harrison 20/e p2710, 19/e p2286)

Wolff-Chaikoff effect • Iodine induced hypothyroidismQ

   (Iodine dependent transient thyroid suppression)
Jod-Basedow’s effect • Iodine induced hyperthyroidismQ
131. Ans. d. Oxygen consumption (Ref: Harrison 20/e p2712, 19/e p2296)
• Beta-blockers do not correct the underlying metabolic abnormalities (i.e. does not affect the oxygen consumption)

Beta Blockers in Thyrotoxicosis

Advantages Limitations
Alleviates adrenergic manifestations: • Beta blockers do not significantly affect the thyroid statusQ, it
• Sweating, tremorQ reduces to some extent the conversion of T4 to T3.
• Tachycardia, palpitationsQ • Beta blockers do not correctQ the underlying metabolic
Section 1

• Nervousness, anxietyQ abnormalities (i.e. does not affect the oxygen consumption) Q

132. Ans. a. Surgery for thyroiditis 133. Ans. a. Early diastolic murmur 134. Ans. b. Radioactive iodine
135. Ans. d. Elevated serum CPK level
• Both thyrotoxicosis and malignant hyperthermia may cause myopathy, but in hyperthyroidism serum CPK is often normal.
136. Ans. d. All
137. Ans. a. Hot nodule (Ref: Schwartz 10/e p1533; Sabiston 19/e p896; Bailey 27/e p804; Harrison 20/e p2713, 19/e p2302)
138. Ans. a. Inadequate control of hyperthyroidism 139. Ans. b. Increased CPK levels
140. Ans. a. Thyroid storm 141. Ans. a. Hashimoto’s thyroiditis
142. Ans. b. Graves’ disease; d. Plummer’s disease; e. Struma ovarii (Ref: Harrison 20/e p2703, 19/e p2293)
 Thyroid 83

143. Ans. d. Hair loss 144. Ans. a. Iodides

145. Ans. d. Inadequate preoperative preparation

Section 1
146. Ans. c. Radioiodine

GRAVE’S DISEASE
147. Ans. a. More common in males (Ref: Schwartz 10/e p1531-1533; Sabiston 20/e p892; Bailey 27/e p811; Harrison 20/e p2703, 19/e p2293)
148. Ans. d. All of the above (Ref: William’s Endocrinology 10/e p479)
Complications of Radioactive Iodine (I131) Therapy
Acute Long-term
• Bone marrow suppressionQ • Chronic sialedenitis, taste dysfunction
• Cerebral edema & hemorrhageQ (brain • Fertility: Ovarian & testicular damage leading to infertility & increased abortion rate
metastasis) • Hematologic: Bone marrow suppressionQ, LeukemiaQ
• Nausea & vomitingQ • HypoparathyroidismQ
• Neck pain, swelling • Increased risk of cancer: Anaplastic carcinoma thyroidQ, carcinoma stomach,
• Sialedenitis, thyroiditis carcinoma bladder lung & breast, HCC
• Vocal cord paralysisQ • Pulmonary fibrosis
149. Ans. d. Hypothyroidism
150. Ans. b. Age >40 years; c. Elderly; e. Presence of associated co-morbidities (Ref: Schwartz 10/e p1532-1533; Sabiston 20/e p892-893; Bailey
27/e p812; Harrison 20/e p2706, 19/e p2296)
151. Ans. a. Thyrotoxicosis 152. Ans. c. Radioiodine
153. Ans. c. Common in male (Ref: Schwartz 10/e p; Sabiston 20/e p; Bailey 27/e p)
154. Ans. c. Remissions and exacerbations are not infrequent

HYPOTHYROIDISM
155. Ans. a. Serum TSH level (Ref: Schwartz 10/e p1529; Sabiston 20/e p895; Bailey 27/e p802; Harrison 20/e p2701, 19/e p2288)

• The ultrasensitive TSH assay has become the most sensitive and specific test for the diagnosis of hyper- and hypothyroidism
and for optimizing T4 therapyQ.
• The enhanced sensitivity and specificity of TSH assays have greatly improved laboratory assessment of thyroid functionQ.

156. Ans. a. Sheehan’s syndrome (Harrison 20/e p2734, 19/e p2257)

Endocrine Surgery
Sheehan’s syndrome causes hypopituitarism leading to decreased TSHQ.

POST THYROIDECTOMY COMPLICATIONS

157. Ans. b. Close to the gland (Schwartz 10/e p1551-1554; Sabiston 20/e p913; Bailey 27/e p813)
• Both superior and inferior thyroid vessels should be ligated close to the thyroidQ.
• Superiorly, to avoid injury to the external branch of the superior laryngeal nerve.
• Inferiorly, to minimize devascularization of the parathyroids (extracapsularQ dissection) or injury to the RLNQ.

Thyroidectomy: Schwartz 10/e p1553

• The dissection plane is kept as close to the thyroid as possible and the superior pole vessels are individually identified, skeletonized,
ligated, and divided low on the thyroid gland to avoid injury to the external branch of the superior laryngeal nerveQ
• The inferior thyroid vessels are dissected, skeletonized, ligated, and divided as close to the surface of the thyroid gland as
possible to minimize devascularization of the parathyroids (extracapsular dissection) or injury to the RLNQ.

158. Ans. d. Hypercalcemia (Ref: Schwartz 10/e p1556; Sabiston 20/e p920; Bailey 27/e p815)
159. Ans. c. Removing sutures from all layers in the ward and evacuation of hematoma
160. Ans. d. Apparent exophthalmos (Ref: Harrison 20/e p3173, 19/e p196, 208)
Horner’s Syndrome
Clinical Features Less Common Features
• PtosisQ • Hyperactive accommodation
• Miosis (constricted pupil)Q • Hypochromic heterochromia
• AnhydrosisQ • Hypotony
• EnopthalmosQ • Hyperaemia
• Loss of ciliospinal reflexesQ
 84 Surgery Essence

161. Ans. b. Medial medullary syndrome (Ref: Harrison 20/e p3173, 19/e p196, 208)
162. Ans. d. Mydriasis
163. Ans. a. As close to the thyroid gland as possible (Ref: Schwartz 10/e p1553; Sabiston 20/e p913)
164. Ans. c. Inferior thyroid artery is ligated away from gland; d. Capsule is kept intact (Ref: Schwartz 10/e p1553)

• The inferior thyroid vessels are dissected, skeletonized, ligated, and divided as close to the surface of the thyroid gland as
possible to minimize devascularization of the parathyroids (extracapsular dissection) or injury to the RLNQ.
• Dissection is extracapsular (Capsule is removed) Q.
Endocrine Surgery

165. Ans. b. 2–5 days 166. Ans. a. Hypocalcemia

167. b. Oral calcium and vitamin D (Ref: Sabiston 20/e p919, 19/e p921; Bailey 27/e p815)

Management of Post-operative Hypocalcemia

Transient Hypocalcemia Prolonged or Permanent Hypocalcemia
• Asymptomatic with calcium level >8 mg/dL: No treatmentQ • Oral calcium with vitamin DQ
• Mild symptoms or calcium level <8 mg/dL: Oral calciumQ
• Severe Symptoms: IV calciumQ

• If hypocalcemia is expected to be prolonged or permanent (as following a 3 and 1/2 gland parathyroid resection or following
total parathyroidectomy with autograft) then oral calcium should be started as soon as possible with vitamin D.

168. Ans. d. Oral calcium 169. Ans. a. IV calcium gluconate

170. Ans. d. Remove the stitch and take the patient to O.T. 171. Ans. a. Respiratory obstruction
172. Ans. a. Open immediately 173. Ans. a. Respiratory obstruction
174. Ans. a. Hypocalcemia 175. Ans. b. Open the operative site
176. Ans. d. Open the wound sutures in the ward 177. Ans. a. 0.1–0.2 mg (Ref: Harrison 19/e p2306)

• Daily replacement dose of thyroxine: 1.6 µg/Kg body weight (0.1–0.15 gm) Q
• For TSH suppression (in PTC and FTC), dose of thyroxine: 2.7 µg/Kg body weightQ

178. Ans. c. Hypocalcemia

• Tracheomalacia and collapse of the larynx, wound hematoma with compression of the trachea and thyroid storm are early
life threatening complications of thyroidectomyQ.
• Hypocalcemia which occurs after 2–5 days after operation and severity of causing life threatening situation is least with
hypocalcemia as compared to the given options.

179. Ans. b. Recurrent laryngeal nerve 180. Ans. c. Superior thyroid artery

THYROIDITIS
181. Ans. a. Anti-TPO (Ref: Schwartz 10/e p1535; Sabiston 20/e p891; Bailey 27/e p821; Harrison 20/e p2699, 19/e p2290)
182. Ans. b. Subacute thyroiditis (Ref: Schwartz 10/e p1535; Sabiston 20/e p891; Bailey 27/e p822; Harrison 20/e p2708, 19/e p2298)
183. Ans. a. Thyroid peroxidase antibodies 184. Ans. b. ↑ESR 185. Ans. d. Orphan Annie eye nuclei
186. Ans. b. Hashimoto’s disease 187. Ans. a. Hashimoto’s thyroiditis 188. Ans. c. Hashimoto’s thyroiditis
189. Ans. c. Increased radioactive iodine uptake 190. Ans. a. Autoimmune in etiology
Section 1

191. Ans. c. In the thyrotoxic phase radioiodine uptake is increased 192. Ans. b. Hashimoto’s thyroiditis
193. Ans. d. Reidel’s thyroiditis (Ref: Schwartz 10/e p1536; Sabiston 20/e p891; Bailey 27/e p822)
194. Ans. c. Riedel’s thyroiditis
195. Ans. c. Subacute thyroiditis (Ref: Schwartz 10/e p1535; Sabiston 20/e p891)
Diagnosis in this case is subacute thyroiditis. Symptoms are more severe in acute thyroiditis with complications and acute thyroiditis is
more common in children.
196. Ans. c. Thyroglobulins 197. Ans. c. To overcome pressure on trachea or esophagus
198. Ans. b. Antithyroid nuclear antibodies 199. Ans. a. Subacute lymphocytic thyroiditis
200. Ans. d. Reidel’s thyroiditis 201. Ans. c. Gaint cell infiltration
 Thyroid 85

THYROGLOSSAL CYST AND FISTULA

202. Ans. d. Thyroglossal cyst/fistula (Ref: Schwartz 10/e p1521; Sabiston 20/e p1861)

Section 1
203. Ans. a. Does not move with deglutition
204. Ans. a. Thyroglossal cyst (Ref: Schwartz 10/e p1521; Sabiston 20/e p1861)
205. Ans. c. Thyroglossal cyst 206. Ans. c. Subhyoid
207. Ans. c. Incision and drainage is the treatment of choice 208. Ans. a. Papillary
209. Ans. c. Excision of central part of hyoid bone and cone of tongue muscles upto foramen caecum
210. Ans. a. Surgical removal

THYROID ANATOMY AND PHYSIOLOGY

211. Ans. a. Jod-Basedow effect (Ref: Schwartz 10/e p1526; Sabiston 20/e p886; Harrison 20/e p2710, 19/e p2286)
212. Ans. b. 0.04 mIU/L (Ref: The thyroid: a Fundamental and Clinical Text (Lippincott Williams) 2008/329-330)

The lower functional limit for third generation TSH assays is about 0.01 to 0.02 mIU/L.
213. Ans. b. Inferior thyroid artery 214. Ans. b. Inversely 215. Ans. c. 18–20 gm
216. Ans. a. Nephrotic syndrome
• In Nephrotic syndrome, iodine binding proteins are decreased.
217. Ans. c. 2nd and 3rd and 4th tracheal cartilage (Ref: Schwartz 10/e p1523; Sabiston 20/e p880-882)
Isthmus that is located just inferior to the cricoid cartilage, usually anterior to the 2nd and 3rd tracheal cartilages.

Thyroid Gland
• Normal weight of thyroid gland: 20–25 gmsQ
• Thyroid is storage site of > 90% of body’s iodine contentQ
• Daily iodine requirement: 100–150 µgQ
• Father of thyroid surgery: Theodor KocherQ
• Gland weight varies inversely with iodine intakeQ.
• Isthmus that is located just inferior to the cricoid cartilage, usually anterior to 2nd & 3rd (mainly) and 4th tracheal ringsQ.
• A pyramidal lobe is present in about 50% of patients.
• Thyroid capsule is condensed into the posterior suspensory or Berry’s ligamentQ near the cricoid cartilage & upper tracheal

Endocrine Surgery
rings.
• Thyroid gland has a thin capsule of connective tissue, which extends into glandular parenchyma & divides each lobe into
irregularly shaped and sized lobules.
• External laryngeal nerve runs close to the superior thyroid artery and the recurrent laryngeal nerve runs close to the inferior
thyroid arteryQ.
Coverings of the Gland
• True capsule: Thin capsule of connective tissue, which extends into the glandular parenchyma & divides each lobe into irregularly
shaped & sized lobules.
• False capsule is derived from pretracheal fascia.

Beahr’s Triangle
• Boundaries: Base: Common carotid artery; Superiorly: Inferior thyroid artery; Inferiorly: RLNQ
• Helps in identifying RLN & avoiding its injuryQ

MISCELLANEOUS
218. Ans. d. All the above (www.medixon.com)

Scabard (Saber-Sheath) Trachea

• Flattening of trachea caused by lateral compressionQ by swellings or tumors
• Causes: Carcinoma thyroid, thyroiditis, carcinoma larynx, goitreQ

219. Ans. b. Tracheostomy (Ref: Nelson 19/e p2284)

Partial thyroidectomy is preferred over tracheostomy.
 86 Surgery Essence

220. Ans. a. I-131 221. Ans. a. Radioiodine is contraindicated

222. Ans. b. Chromosome 7q (Ref: Harrison 20/e p2693, 19/e p2284; Schwartz 10/e p1534)

Pendred’s Syndrome
• Consists of congenital sensorineural hearing loss + goitreQ
• Due to defect in sulfate transport protein (chromosome 7qQ) to the thyroid gland and cochlea

Rafetoff Syndrome End organ resistance to T4Q

223. Ans. a. Lingual thyroid (Ref: Schwartz 10/e p1522)

Endocrine Surgery

Reddish swelling in the region of foramen caecum is Lingual thyroid.

Lingual Thyroid
• Forms a rounded swelling at the back of tongue at the foramen caecumQ
• It may represent the only thyroid tissue presentQ
• May cause dysphasia, impairment of speech, respiratory obstruction or hemorrhage
• Medical treatment options include administration of exogenous thyroid hormone to suppress TSH and RAI ablation followed
by hormone replacement.
• Surgical excision is rarely needed but, if required, should be preceded by an evaluation of normal thyroid tissue in the neck to
avoid inadvertently rendering the patient hypothyroid.

224. Ans. d. Benign lesion; e. Included in Teratoma (Ref: Shaws Gynecology 14/e p336-337)

Struma Ovarii
• Highly specialized variety of teratoma
• A benign ovarian tumor containing thyroid tissueQ
• The tumor is solid and consisting entirely of thyroid tissue
• Some cases develop thyrotoxicosisQ
• Most of the tumor is innocent, but malignant transformation have been recorded

225. Ans. c. Di George syndrome (Ref: Schwartz 10/e p1574)

Di-George Syndrome

Characterized by
• Congenital cardiac defects, particularly those involving great vesselsQ
• Hypocalcemic tetany due to failure of parathyroid developmentQ
• Absence of normal thymus, T-cell immunodeficiencyQ

226. Ans. d. Pizzillo’s method.

Section 1