A 9-year-old boy has a 2 cm painless midline swelling just below the hyoid bone. It moves upwards when he swallows and when he protrudes his tongue. Ultrasound shows a cyst and a normal thyroid gland in its usual position. Which operation is recommended?

Sistrunk operation with the central hyoid body

Total thyroidectomy with the cyst

Simple enucleation of the cyst alone

Incision and drainage of the cyst

A 42-year-old woman has a 3 cm thyroid nodule with a normal TSH. Ultrasound-guided FNAC is reported as Bethesda category IV, 'follicular neoplasm'. There is no lymphadenopathy. What is the most appropriate next step?

Radioiodine ablation of the nodule

Total thyroidectomy with neck dissection

Four hours after a hemithyroidectomy, a 38-year-old man in the surgical ward becomes restless and breathless. The front of his neck is tense and swollen, the drain is blocked, and he has stridor. SpO2 is 90% on oxygen. What should the ward surgeon do first?

Open the skin and strap sutures at the bedside

Arrange an urgent CT scan of the neck

Give IV hydrocortisone and observe

Shift him to theatre for planned re-exploration

Thyroid swellings and endocrine surgery

28 NEET-PG practice questions on Thyroid swellings and endocrine surgery, part of General Surgery. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
A 30-year-old man has a 3 cm hard nodule in the right thyroid lobe. FNAC shows spindle and polygonal cells in a background of amyloid, and serum calcitonin is high. He also reports episodes of headache, sweating and palpitations, and his BP is 170/104 mmHg. Before thyroidectomy, which investigation is essential?
1. ASerum thyroglobulin level
2. BPlasma free metanephrines
3. CAnti-TPO antibody titre
4. DRadioiodine uptake scan
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Answer: B · Plasma free metanephrines
Amyloid stroma and raised calcitonin mean medullary thyroid carcinoma, a tumour of the parafollicular C cells. Episodic headache, sweating and palpitations with hypertension suggest a phaeochromocytoma, so MEN 2 (RET proto-oncogene) is likely. A phaeochromocytoma must be excluded with plasma free (or urinary fractionated) metanephrines before any thyroid surgery: if present, it is removed first after alpha-blockade, because anaesthesia on an unprepared phaeochromocytoma can cause a fatal hypertensive crisis. Calcium (for hyperparathyroidism in MEN 2A) and RET testing for the family follow.
- A: Thyroglobulin is a marker for follicular-cell (papillary and follicular) cancers.
- C: Anti-TPO antibodies point to autoimmune thyroiditis, not this tumour.
- D: C cells do not trap iodine, so a radioiodine scan does not help in MTC.
Question 2 · Medium
A 9-year-old boy has a 2 cm painless midline swelling just below the hyoid bone. It moves upwards when he swallows and when he protrudes his tongue. Ultrasound shows a cyst and a normal thyroid gland in its usual position. Which operation is recommended?
1. ATotal thyroidectomy with the cyst
2. BSistrunk operation with the central hyoid body
3. CSimple enucleation of the cyst alone
4. DIncision and drainage of the cyst
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Answer: B · Sistrunk operation with the central hyoid body
A midline cyst that rises on tongue protrusion is a thyroglossal cyst, a remnant of the thyroglossal duct along which the thyroid descended from the foramen caecum. The Sistrunk operation removes the cyst, the tract and the central part of the body of the hyoid, with a core of tissue towards the foramen caecum, which brings recurrence down sharply. Ultrasound first confirms normal thyroid tissue in the neck, so that the swelling is not the patient's only thyroid tissue.
- A: The thyroid is normal and is not removed for a thyroglossal cyst.
- C: Removing the cyst alone leaves the tract and has a high recurrence rate.
- D: Drainage leads to infection, recurrence and a discharging fistula.
Question 3 · Medium
A 42-year-old woman has a 3 cm thyroid nodule with a normal TSH. Ultrasound-guided FNAC is reported as Bethesda category IV, 'follicular neoplasm'. There is no lymphadenopathy. What is the most appropriate next step?
1. ARepeat FNAC after 3 months
2. BRadioiodine ablation of the nodule
3. CDiagnostic hemithyroidectomy
4. DTotal thyroidectomy with neck dissection
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Answer: C · Diagnostic hemithyroidectomy
Follicular adenoma and follicular carcinoma look the same on cytology; carcinoma is defined only by capsular or vascular invasion, which needs the whole nodule on histology. Bethesda IV is therefore managed by diagnostic lobectomy (hemithyroidectomy), with molecular testing as an alternative where available. If histology shows carcinoma needing further treatment, completion thyroidectomy follows.
- A: Repeat cytology cannot show capsular or vascular invasion, so it does not settle Bethesda IV.
- B: Radioiodine is not used to treat an undiagnosed euthyroid nodule.
- D: Neck dissection is not indicated without proven cancer or involved nodes.
Question 4 · Medium
Four hours after a hemithyroidectomy, a 38-year-old man in the surgical ward becomes restless and breathless. The front of his neck is tense and swollen, the drain is blocked, and he has stridor. SpO2 is 90% on oxygen. What should the ward surgeon do first?
1. AOpen the skin and strap sutures at the bedside
2. BArrange an urgent CT scan of the neck
3. CGive IV hydrocortisone and observe
4. DShift him to theatre for planned re-exploration
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Answer: A · Open the skin and strap sutures at the bedside
A tense neck swelling with stridor after thyroid surgery is a compressive haematoma, which obstructs venous return and causes laryngeal oedema. The life-saving first step is to open the wound at the bedside, cutting the skin and strap muscle sutures to release the clot, before transfer to theatre to control the bleeding vessel. Intubation through an oedematous larynx is difficult until the pressure is relieved.
- B: Imaging wastes time in an airway emergency with an obvious clinical cause.
- C: Steroids do not relieve the pressure of a haematoma.
- D: Waiting to move him to theatre can be fatal when the airway is already obstructed.
Question 5 · Medium
A 17-year-old boy who is tall and thin with long limbs has thick, bumpy lips and small nodules on the tongue. He has had constipation since childhood. A hard nodule is found in his thyroid, and serum calcitonin is very high. Serum calcium is normal. What is the most likely diagnosis?
1. AMEN 1
2. BNeurofibromatosis type 1
3. CMEN 2A
4. DMEN 2B
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Answer: D · MEN 2B
Medullary thyroid carcinoma with mucosal neuromas of the lips and tongue, a marfanoid habitus and intestinal ganglioneuromatosis (causing constipation) is MEN 2B, due to a germline RET mutation. MEN 2B also carries phaeochromocytoma but, unlike MEN 2A, not hyperparathyroidism. Its medullary carcinoma is the most aggressive of the MEN syndromes, so carriers identified in infancy have prophylactic thyroidectomy very early in life.
- A: MEN 1 involves parathyroid, pancreas and pituitary, not medullary carcinoma.
- B: NF1 has cafe-au-lait spots and neurofibromas, not medullary carcinoma with mucosal neuromas.
- C: MEN 2A has medullary carcinoma, phaeochromocytoma and hyperparathyroidism, without mucosal neuromas or marfanoid habitus.
Question 6 · Medium
A 34-year-old man is found to have serum calcium 10.9 mg/dL (8.5-10.5) during a health check. He has no symptoms; his father and sister also have a mildly raised calcium. PTH is 58 pg/mL (15-65), and the 24-hour calcium/creatinine clearance ratio is 0.006. What is the most likely diagnosis?
1. AFamilial hypocalciuric hypercalcaemia
2. BPrimary hyperparathyroidism from an adenoma
3. CTertiary hyperparathyroidism
4. DVitamin D intoxication
Answer and explanation in LearnFree account
Question 7 · Medium
A 70-year-old man has a hard, fixed thyroid mass that has doubled in size over 3 weeks, with hoarseness and dysphagia. Core biopsy confirms anaplastic thyroid carcinoma, and CT shows invasion of the trachea and multiple lung nodules. The oncologist asks for one molecular test on the tumour before deciding systemic treatment. Which test is most useful?
1. ABRAF V600E mutation testing
2. BHER2 amplification testing
3. CRET proto-oncogene testing
4. DBCR::ABL1 fusion testing
Answer and explanation in LearnFree account
Question 8 · Easy
A 58-year-old woman is admitted to the orthopaedic ward with a pathological fracture of the right humerus. She has had a slowly enlarging thyroid swelling for years. Biopsy of the bone lesion shows well-formed thyroid follicles. Which thyroid cancer most typically spreads by this route?
1. AFollicular carcinoma
2. BAnaplastic carcinoma
3. CPapillary carcinoma
4. DPrimary thyroid lymphoma
Answer and explanation in LearnFree account
Question 9 · Medium
A 36-year-old man from Hyderabad has recurrent duodenal ulcers despite a full course of proton pump inhibitors, and kidney stones. His wife reports he has lost interest in sex. Serum calcium is 11.4 mg/dL with a high PTH, fasting gastrin is very high, and prolactin is 180 ng/mL. When his parathyroids are explored, what is the expected finding and operation?
1. ADouble adenoma; excision of two glands
2. BParathyroid carcinoma; en bloc resection
3. CFour-gland hyperplasia; subtotal parathyroidectomy
4. DSingle adenoma; focused excision of one gland
Answer and explanation in LearnFree account
Question 10 · Easy
On the second day after total thyroidectomy for a multinodular goitre, a 45-year-old woman complains of tingling around the lips and fingertips. Tapping over the facial nerve in front of the ear makes the corner of her mouth twitch, and serum calcium is 6.9 mg/dL (8.5-10.5). What is the immediate treatment?
1. ASlow intravenous 10% calcium gluconate
2. BIntravenous magnesium sulphate alone
3. COral calcium carbonate tablets alone
4. DOral vitamin D3 60,000 IU weekly
Answer and explanation in LearnFree account
Question 11 · Easy
A 35-year-old woman has a 2.5 cm solitary thyroid nodule noticed while combing her hair. She is clinically euthyroid and her TSH is normal. Ultrasound shows a solid hypoechoic nodule with microcalcifications and irregular margins. What is the next best step?
1. AUltrasound-guided FNAC of the nodule
2. BTechnetium thyroid scintigraphy
3. CRepeat ultrasound after 6 months
4. DTotal thyroidectomy without cytology
Answer and explanation in LearnFree account
Question 12 · Medium
A 30-year-old man has a 3.5 cm right thyroid nodule. FNAC shows papillary carcinoma, and ultrasound-guided FNAC of a 2 cm node at right level III also shows metastatic papillary carcinoma. CT shows no distant spread. What is the most appropriate surgery?
1. ATotal thyroidectomy with radical neck dissection
2. BTotal thyroidectomy alone, then radioiodine
3. CRight hemithyroidectomy with excision of the node
4. DTotal thyroidectomy, central and right lateral neck dissection
Answer and explanation in LearnFree account
Question 13 · Medium
A 50-year-old woman is extubated after total thyroidectomy for a large goitre. In the recovery room she develops inspiratory stridor and falling SpO2, although her voice is fair. There is no neck swelling and the wound is flat. Laryngoscopy shows both vocal cords lying close to the midline. What is the most appropriate management?
1. AOpening the wound to evacuate a haematoma
2. BRe-intubation, followed by tracheostomy if needed
3. CIV calcium gluconate for laryngeal spasm
4. DNebulised adrenaline and observation
Answer and explanation in LearnFree account
Question 14 · Easy
A 40-year-old Carnatic singer underwent hemithyroidectomy at a district hospital. Her voice is clear and she has no stridor, but she now cannot reach high notes and her voice tires quickly. Which nerve was most likely injured?
1. AExternal branch of the superior laryngeal nerve
2. BInternal branch of the superior laryngeal nerve
3. CRecurrent laryngeal nerve on the operated side
4. DAnsa cervicalis supplying the strap muscles
Answer and explanation in LearnFree account
Question 15 · Medium
A surgery postgraduate in a teaching hospital prepares notes on papillary carcinoma of the thyroid: 1. It is the most common malignant tumour of the thyroid. 2. It spreads mainly by lymphatics to the cervical nodes. 3. It can be diagnosed on FNAC by its nuclear features. 4. Its diagnosis needs histological proof of capsular or vascular invasion. Which statements are correct?
1. A1, 2 and 3 only
2. B1 and 2 only
3. C2, 3 and 4 only
4. D1, 3 and 4 only
Answer and explanation in LearnFree account
Question 16 · Hard
A 38-year-old woman had a total thyroidectomy with central neck dissection for papillary carcinoma, and radioiodine ablation is planned. The nuclear medicine physician lists four steps for preparation: 1. Raise TSH above about 30 mIU/L by thyroxine withdrawal or recombinant human TSH. 2. Follow a low-iodine diet for 1-2 weeks before treatment. 3. Get a contrast-enhanced CT of the neck in the week before treatment to restage. 4. Exclude pregnancy before the dose. Which steps are correct?
1. A1, 2 and 4 only
2. B1, 2, 3 and 4
3. C1 and 4 only
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 17 · Medium
A 45-year-old woman with no family history of thyroid or adrenal disease has a 2 cm thyroid nodule. FNAC and a markedly raised calcitonin confirm medullary carcinoma; plasma metanephrines are normal. Which further test should she be offered even though the tumour appears sporadic?
1. AWhole-body radioiodine scan
2. BGermline RET proto-oncogene testing
3. CSerum thyroglobulin estimation
4. DBRAF V600E testing of the FNAC sample
Answer and explanation in LearnFree account
Question 18 · Medium
A 66-year-old woman with Hashimoto thyroiditis on levothyroxine for 15 years notices a rapid, painless enlargement of the thyroid over 6 weeks, with a feeling of pressure in the neck. FNAC shows sheets of monotonous large atypical lymphoid cells, unlike the mixed lymphocytes of her previous FNAC. What is the most likely diagnosis?
1. AFlare of Hashimoto thyroiditis
2. BAnaplastic carcinoma of thyroid
3. CPrimary thyroid lymphoma
4. DHurthle cell carcinoma
Answer and explanation in LearnFree account
Question 19 · Hard
A 50-year-old man has severe fatigue, polyuria, bone pain and recent hoarseness. A hard 3 cm mass is felt in the left lower neck. Serum calcium is 15.4 mg/dL (8.5-10.5) and PTH 1,150 pg/mL (15-65). Ultrasound shows a lobulated mass behind the left thyroid lobe that appears to invade it. After correcting his calcium, what is the most appropriate operation?
1. ASubtotal parathyroidectomy of all glands
2. BEn bloc resection with the left thyroid lobe
3. CFocused excision of the left lower gland
4. DBiopsy followed by radiotherapy alone
Answer and explanation in LearnFree account
Question 20 · Hard
A 50-year-old man had a right hemithyroidectomy for a 4.5 cm nodule reported as Bethesda IV on FNAC. Histology shows follicular carcinoma with invasion through the capsule and tumour in several capsular blood vessels. The left lobe was normal on ultrasound. What is the most appropriate further management?
1. ABilateral modified radical neck dissection
2. BThyroxine suppression and ultrasound follow-up
3. CExternal beam radiotherapy to the thyroid bed
4. DCompletion thyroidectomy followed by radioiodine
Answer and explanation in LearnFree account
Question 21 · Medium
A 47-year-old woman has palpitations and weight loss. She has a 3 cm nodule in the left thyroid lobe, no eye signs, a suppressed TSH and raised free T4. Technetium scintigraphy shows intense uptake in the nodule with almost no uptake in the rest of the gland. What is the most likely diagnosis?
1. AToxic adenoma
2. BPapillary carcinoma
3. CGraves disease
4. DSubacute thyroiditis
Answer and explanation in LearnFree account
Question 22 · Hard
A 60-year-old woman with known primary hyperparathyroidism is brought to casualty drowsy and confused after a week of vomiting. She is clinically dehydrated, BP 96/60 mmHg, serum calcium 15.6 mg/dL (8.5-10.5) and creatinine 2.1 mg/dL. The duty doctor considers four measures: 1. Intravenous 0.9% saline in large volumes. 2. Intravenous zoledronic acid. 3. Oral hydrochlorothiazide to increase calcium excretion. 4. Subcutaneous calcitonin. Which measures are appropriate?
1. A1 and 4 only
2. B1, 2 and 4 only
3. C1, 2 and 3 only
4. D2, 3 and 4 only
Answer and explanation in LearnFree account
Question 23 · Easy
A 21-year-old man, treated at the age of 9 with neck and mediastinal radiotherapy for Hodgkin lymphoma, is found to have a 1.8 cm solid thyroid nodule at his annual follow-up. TSH is normal. If this nodule proves malignant, which type of thyroid cancer is it most likely to be?
1. AFollicular carcinoma
2. BPapillary carcinoma
3. CMedullary carcinoma
4. DAnaplastic carcinoma
Answer and explanation in LearnFree account
Question 24 · Easy
A 55-year-old woman is found on a routine health check to have serum calcium 11.2 mg/dL with a raised PTH; she has no family history of endocrine disease. At neck exploration, which parathyroid lesion is the surgeon most likely to find?
1. AMultiple parathyroid adenomas
2. BParathyroid carcinoma
3. CSingle parathyroid adenoma
4. DFour-gland parathyroid hyperplasia
Answer and explanation in LearnFree account
Question 25 · Hard
A 48-year-old woman with long-standing primary hyperparathyroidism, bone pain and a serum ALP of 840 U/L (40-130) undergoes excision of a large parathyroid adenoma. On day 3 she has carpopedal spasm. Serum calcium is 6.8 mg/dL (8.5-10.5), phosphate 1.9 mg/dL (2.5-4.5), magnesium low, and PTH 72 pg/mL (15-65). What is the most likely cause?
1. APermanent hypoparathyroidism
2. BHungry bone syndrome
3. CPseudohypoparathyroidism
4. DPersistent hyperparathyroidism
Answer and explanation in LearnFree account

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Thyroid swellings and endocrine surgery

A 9-year-old boy has a 2 cm painless midline swelling just below the hyoid bone. It moves upwards when he swallows and when he protrudes his tongue. Ultrasound shows a cyst and a normal thyroid gland in its usual position. Which operation is recommended?

A 42-year-old woman has a 3 cm thyroid nodule with a normal TSH. Ultrasound-guided FNAC is reported as Bethesda category IV, 'follicular neoplasm'. There is no lymphadenopathy. What is the most appropriate next step?

Four hours after a hemithyroidectomy, a 38-year-old man in the surgical ward becomes restless and breathless. The front of his neck is tense and swollen, the drain is blocked, and he has stridor. SpO2 is 90% on oxygen. What should the ward surgeon do first?

A 17-year-old boy who is tall and thin with long limbs has thick, bumpy lips and small nodules on the tongue. He has had constipation since childhood. A hard nodule is found in his thyroid, and serum calcitonin is very high. Serum calcium is normal. What is the most likely diagnosis?

A 34-year-old man is found to have serum calcium 10.9 mg/dL (8.5-10.5) during a health check. He has no symptoms; his father and sister also have a mildly raised calcium. PTH is 58 pg/mL (15-65), and the 24-hour calcium/creatinine clearance ratio is 0.006. What is the most likely diagnosis?

A 58-year-old woman is admitted to the orthopaedic ward with a pathological fracture of the right humerus. She has had a slowly enlarging thyroid swelling for years. Biopsy of the bone lesion shows well-formed thyroid follicles. Which thyroid cancer most typically spreads by this route?

A 35-year-old woman has a 2.5 cm solitary thyroid nodule noticed while combing her hair. She is clinically euthyroid and her TSH is normal. Ultrasound shows a solid hypoechoic nodule with microcalcifications and irregular margins. What is the next best step?

A 30-year-old man has a 3.5 cm right thyroid nodule. FNAC shows papillary carcinoma, and ultrasound-guided FNAC of a 2 cm node at right level III also shows metastatic papillary carcinoma. CT shows no distant spread. What is the most appropriate surgery?

A 40-year-old Carnatic singer underwent hemithyroidectomy at a district hospital. Her voice is clear and she has no stridor, but she now cannot reach high notes and her voice tires quickly. Which nerve was most likely injured?

A 45-year-old woman with no family history of thyroid or adrenal disease has a 2 cm thyroid nodule. FNAC and a markedly raised calcitonin confirm medullary carcinoma; plasma metanephrines are normal. Which further test should she be offered even though the tumour appears sporadic?

A 47-year-old woman has palpitations and weight loss. She has a 3 cm nodule in the left thyroid lobe, no eye signs, a suppressed TSH and raised free T4. Technetium scintigraphy shows intense uptake in the nodule with almost no uptake in the rest of the gland. What is the most likely diagnosis?

A 21-year-old man, treated at the age of 9 with neck and mediastinal radiotherapy for Hodgkin lymphoma, is found to have a 1.8 cm solid thyroid nodule at his annual follow-up. TSH is normal. If this nodule proves malignant, which type of thyroid cancer is it most likely to be?

A 55-year-old woman is found on a routine health check to have serum calcium 11.2 mg/dL with a raised PTH; she has no family history of endocrine disease. At neck exploration, which parathyroid lesion is the surgeon most likely to find?