Questions on Thyroid Surgery

Welcome to surgery questions on thyroid surgery. These questions from entrance exams are often repeated.

Q) What is not an indication of surgery over Radio active Iodine ( RAI) therapy  in Grave's disease?

a) Suspicious thyroid nodule

b) Young patient

c) Thyroid gland 50 g 

d) Desire to conceive soon

Ans  c

Indications of Surgery over RAI 

a) confirmed cancer or suspicious thyroid nodules

(b) young

(c) desire to conceive soon (<6 months) after treatment,

(d) have had severe reactions to antithyroid medications,

(e)have large goiters (>80 g) causing compressive symptoms

(f) are reluctant to undergo RAI therapy.

Schwartz page 1637

Q) 40 year old lady was on anti thyroid medications which she stopped for 2 weeks. She presented in emergency with high grade fever and hypotension. What is not a part of further management?

a) Oxygen

b) Beta blockers

c) Radio active Iodine

d) Lugol's idodine

Ans  c

This is Thyroid storm

Predisposing factors for thyroid storm are 

  1. Cessation of antithyroid medications
  2. Infection
  3. Thyroid or non thyroid surgery in untreated thyrotoxicosis
  4. Trauma in patients with untreated thyrotoxicosis.
  5. Amiodarone
  6. Iodinated contrast agents
  7. RAI therapy

Management is 

  1. Beta blockers
  2. Oxygen and hemodynamic support
  3. IV Lugol iodine
  4. PTU
  5. Corticosteroids

Schwartz page 1638


Q1. Which of the following is not true for Hashimoto thyroiditis?

a) It is an autoimmune disease caused by CD4 cells with specificity to thyroid antigens
b) commonly presents as hypothyroidism
c) Surgery is required in almost all cases

d) Hashimoto thyroiditis can progress to lymphoma of thyroid

1. c
Hashimoto's thyroiditis is an autoimmune process that is thought to be initiated by the activation of CD4+T (helper) lymphocytes with specificity for thyroid antigens.
Hypothyroidism is due to cytotoxic cells and autoantibodies.
Primary treatment is Thyroxine and surgery is only indicated for cosmetic reasons .
Hashimoto's thyroiditis  more common in women (male: female ratio 1:10 to 20) between the ages of 30 and 50 years.
Commonly presents as moderately enlarged firm gland discovered on routine physical examination  or the awareness of a painless anterior neck mass, although 20% of patients present with hypothyroidism, and 5% present with hyperthyroidism (hashitoxicosis)
Chances of lymphoma are more in cases with hashimoto's thyroiditis.

 Q 2. In which of the following conditions anti thyroid antibody may not be elevated?
a) Hashimoto thyroiditis
b) Grave's disease
c) Multinodular goitre

d) Lymphoma thyroid

2. d
Antibodies include antithyroglobulin (anti-Tg), antimicrosomal or antithyroid peroxidase (anti-TPO) and thyroid-stimulating immunoglobulin (TSI). Anti-Tg and anti-TPO antibody levels  they indicate the underlying disorder, usually an autoimmune thyroiditis.
Approximately 80% of patients with Hashimoto's thyroiditis have elevated thyroid antibody levels, but levels may also be increased in patients with Graves' disease, multinodular goiter, and, occasionally, with thyroid neoplasms
In Grave's disease antibodies are directed against (TRAbs) (thyroid hormone receptors) (TSI)
Iodine Metabolism
The average daily iodine requirement is 0.1 mg. Iodine is rapidly converted to iodide in stomach and jejunum. Iodide is actively transported into the thyroid follicles.
Thyroid Hormone Synthesis involves four steps
1.Thyroid trapping of iodide
2. Oxidation of iodide into iodine and coupling with tyrosine to form monoiodotyrosine and diiodotyrosine.
3. Coupling to form T3 and T4
4.Hydrolisation of Thyroglobulin to release T3 and T4
In the euthyroid state, T4 is produced and released entirely by the thyroid gland, whereas only 20% of the total T3 is produced by the thyroid. Most of the T3 is produced by peripheral deiodination of T4 in the liver, muscles, kidney, and anterior pituitary,

The thyroid gland  is capable of autoregulation, which allows it to modify its function independent of TSH. As an adaptation to low iodide intake, the gland preferentially synthesizes T3 rather than T4, thereby increasing the efficiency of secreted hormone. In situations of iodine excess, iodide transport, peroxide generation, synthesis, and secretion of thyroid hormones are inhibited.

 Q3. Regarding thyroid and parathyroid neoplasms
a.  Follicular carcinoma of thyroid primarily spreads through lymphatics 
b.  Parathyroid adenoma is the most likely cause of  primary hyperparathyroidism
c.  Hürthle cell carcinoma is a variant of papillary carcinoma of the thyroid 
d  Phaeochromocytoma is detected by measuring urinary 5-HIAA levels



 Q4. A complication of thyroidectomy which can be prevented by prophylaxis is
a) Injury to recurrent laryngeal nerve
b) Hypocalcemia
c) Thyroid Storm


4. c
Thyroid storm, a manifestation of severe thyrotoxicosis, is avoided by prophylactic treatment with propylthiouracil or methimazole prior to surgery.

Q5) What is the next step in investigating a 26 year old male with solitary thyroid nodule 1 cm in size?
a) Radio Isotope scan
b) Thyroid functions (T3,T4, TSH)
c) USG guided FNAC
d) Follow without investigations

5. B
Although some or all of these tests may be required at some stage, the initial investigation would be thyroid function tests to look at whether the patient is hypothyroid or hyperthyroid.
Low TSH means hyperthyroidism and is further evaluated with Radio isotope scan. It also suggests lower chance of malignancy
High TSH suggests hypothyroidism most likely Hashimoto's thyroidits


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