Objectives:

● NOT GIVEN

Resources:
● Davidson
● Current diagnosis & treatment
● Raslan
● Doctor’s note
Done by: H​ elmi alsweirky & Ibrahim albeeshy
Sub-leader: ​Abudllah Alghizzi
Leaders:​ A​ bdulrahman Alsayyari & Monerah Alsalouli
Reviewed by:​ ​Abdullh Alghizzi & Helmi alsweirky

[ ​Color index​ | ​ Important​ | ​Notes​ ​ | ​Extra​ | ​ ​Editing file​ ]

Basic review:

Anatomy of the neck:

- The investing layer of deep cervical fascia lies deep to
the skin. The layer between them is the platysma (it
assists the muscles of facial expression).
- The cervical branch of the facial nerve supplies the
platysma.
- Other than Subcutaneous Lipoma and Sebaceous
cysts, most neck swellings lie deep to platysma.
- The sternocleidomastoid muscle (which is supplied by
the spinal accessory nerve) divides the front of the neck
into anterior and posterior triangles.
- The anterior triangle is further subdivided into:
1-Submental triangle: contains nodes draining central
portion of the lips and tip of the tongue.
2- Submandibular triangle: contains submandibular gland and lymph nodes. The floor of this triangle is formed by
the hyoglossus muscle with the hypoglossal nerve lying on it.
3- Carotid triangle: contains the common carotid artery, internal jugular vein, vagus nerve. Branchial cysts and
carotid body tumors are common in the carotid triangle.
4- The muscular triangle: contains infrahyoid muscles, thyroid gland, larynx, trachea oesophagus, recurrent
laryngeal nerve, inferior laryngeal artery and external laryngeal nerve.
​Most neck masses are painless, but may be painful due to infection and malignant diseases. Rapid enlargement
makes malignant disease more likely. Salivary gland swelling, caused by duct obstruction, enlarges when patient
eats.

Common neck swellings

don’t mix up goiter (​swelling​) with ​dysfunction​!! they are different: we can have one of them
without​ the other.

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CAUSES OF GOITER​: T​ ypes of swellings:
1. Thyroid cyst :

Features - Benign, ​painless​.

Diagnosis Ultrasound ​and ​FNA.

- Thyroid gland is located behind a fascia “pretracheal fascia”, so it is difficult to differentiate
solid mass​ or ​cyst​ by examination“ ​“​Ultrasound and FNA are the best​ options to differentiate
between them.

Treatment ​ spiration​.
A
If it reoccurs up to two times → aspirate cyst again, but the 3rd time surgery is indicated.
(lobectomy)

pics

2. Multinodular goiter (Simple goiter):

What is it? - ​Functional​ problem, it’s ​Hyperplasia of the cells​. It is solid and locally causing dysphagia,
dyspnea, stridor or hoarseness.
- It is the most common thyroid disease​.

Causes The hyperplasia of cells is because of:

1.iodine deficiency1 2.side effect of “lithium” 3.problem in the synthesis (idiopathic).

Clinical - Starts as a ​simple goiter​ then becomes nodular (but the function stays normal). After years,
features some of the nodules will produce excessive amount of thyroxine; we call it ​toxic multinodular
goiter​. ​So simple multinodular goiter may eventually turn into toxic.
- simple multinodular goiter is the most common cause of single nodule (‫)ﻫﻮ اﻟﻮﺣﯿﺪ اﻟﻤﺤﺴﻮس ﺑﯿﻨﻬﻢ‬.
- indication for surgical intervention → if the multinodular goiter restrict the respiration.

Diagnosis - Ultrasound ​and ​FNA​ then ​nuclear (warm) scan.

- ​Warm scan is ​normal​ : like the lobe on the right side of the picture - or
- abnormal either: Hot2(overtaking iodine hyperactive).
Or Cold (circled area): it means that area is not uptaking iodine hence it
is no longer thyroid tissue, indicative of ​malignancies​ in 15% of patients.

1
​Common in iodine deficiency area.
2
In nuclear scan: hot nodule: the nodule uptake the iodine and produce thyroxine more than surrounding tissue, and cold
nodule: it doesn’t uptake iodine (hence it appears lighter in the image) and not functioning.
2
 Presentation The goiter presents incidentally :​ either:
1-toxic goiter:​ associated with ​hyperthyroidism​. E.g. Graves disease, toxic multinodular
goiter (Plummer's disease), and toxic adenoma.
2-Nontoxic goiter:​ asymptomatic goiter but can cause compression symptoms, ​thyroid
function is normal​. It may be diffuse or multinodular.

3. Inflammatory (thyroiditis):

Note It is difficult to differentiate between inflammatory and simple goiter by signs and symptoms,
you need to do aspiration and biopsy. (Even by US they look alike)

Types 1- Acute :​ ​is extremely rare especially biogenic (bacterial3) inflammation.

2- Sub-acute:4 rare noninfectious ​either de Quer​v​ain's disease (hyperthyroidism) that is
associated with an influenza-​like illness (​v​irus) and painful diffuse swelling of the gland, or
Riedel's thyroiditis (hypothyroidism) which is a very rare cause of painless thyroid​.
3- Chronic (Hashimoto's thyroiditis “autoimmune”): ​most common inflammation.​ usually
mixed with simple goiter (painless diffuse swelling), no signs of inflammation like redness.
Starts slightly5 ​hyper​thyroidism → then ​eu​function → lastly​ hypo​thyroidism.

Diagnosis by ​serological markers​ and ​biopsy​ which shows lymphocytes, monocytes, etc.

4. Benign tumor :​ ​ ​90​% of tumors. 5. Malignant tumor :​ ​10​% of tumors.

Usually Follicular adenoma. Types​: 1-Papillary Carcinoma
2- Follicular Carcinoma 3- Medullary
4- Undifferentiated 5- Lymphoma

6. Physiological goiter​ ​(simple diffuse swelling): happens as a result of​ ​increase the demand​ (like in
puberty - due to growth - and in pregnancy...etc ), the body needs thyroxine and the gland will try to
compensate. It’s usually not extremely enlarged.
Fast growth → increased need of thyroxine → thyroid hypertrophy.

Remember: ​Normal​ thyroid function in: Thyroid cyst - Simple multinodular - Malignant tumor -
physiological goiter - Inflammatory.

Case: Ahmed ( ​28 ​year-old) came to the Outpatient clinic ​complaining of​ nervousness, palpitations, sweating, and
weight loss. Clinical examination revealed ​the presence of a goiter​. Hyperthyroidism Thyrotoxicosis can be a
manifestation of a number of thyroid conditions, but the most common are:
1. Grave’s disease: autoimmune disease (inflammatory) causes thyrotoxicosis and it has a direct affect on the eyes. Eye
signs in grave’s disease are very obvious(lid retraction and exophthalmos). Usually affects the young.
2. Toxic multinodular goiter: It starts as a simple goiter, but sometimes with time these nodules may turn into toxic
nodules (which secrete thyroxine).
In nuclear scan, you will see hot nodules. And sometimes only one nodule becomes toxic on nuclear scan.

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sudden onset of severe neck pain, fever, and chills. It usually follows an acute URTI; most often by strep/staph/pneumo
cocci or coliforms. Maybe associated with pyriform sinus fistula. Barium swallow is therefore recommended in recurrents.
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thyroid swelling, head and chest pain, fever, palpitations, and weight loss. Some have no pain (silent thyroiditis), in
which case the condition must be distinguished from Graves disease.
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​Slightly​, not high like graves disease.
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Causes of a solitary thyroid nodule:
1- Thyroid cyst.
2- Dominant nodule in a multinodular goiter ​(most common cause).
3- Degeneration or hemorrhage into a colloid cyst or nodule.
4- Benign tumor.
5- malignancy.

Malignant tumors of the thyroid:

ESSENTIALS OF DIAGNOSIS :
1- ​Painless​ enlarging nodule​ ‫ ﻟﻤﺎ ﯾﻘﻮل اﻟﺒﯿﺸﻨﺖ ﻋﻨﺪي أﻟﻢ اﻓﺮح‬:)
2- ​Lymphadenopathy​ ⇒ specially ipsilateral cervical, high chance of malignancy (specific for, but not
sensitive)6. ​More than 95% of the malignancy conditions don’t have lymphadenopathy​. ‫اﻓﺤﺼﻮا اﻟﻠﻤﻒ ﻧﻮدز ﺑﺎﻻوﺳﻜﻲ‬
3- ​Hoarseness of voice → ​recurrent laryngeal nerve​ involvement​: ​malignancy​ or ​iatrogenic​. (also specific
99%, but not Sensitive)​ ‫ ﻟﻤﺎ ﺗﺸﻮﻓﻮن ﻫﻮرﺳﻨﺲ ﻫﻲ وﺣﺪة ﻣﻦ ﺛﻨﺘﯿﻦ ﯾﺎ ﺗﯿﻮﻣﺮ ﯾﺎ ﺟﺮاح زار اﻟﻤﻨﻄﻘﺔ‬:)
4- ​Dysphagia​ (because of the size).
5- ​Function in malignancy is usually normal​!! MCQ ‫ﻟﺤﺪ ﯾﻘﻮل ﻟﻲ ﺑﺎﻻﺧﺘﺒﺎر ﺛﺎﯾﺮوﺗﻮﻛﺴﯿﻜﻮﺳﺲ‬
6- Investigation: Whenever you see ​cold​ nodule ​(nuclear)​ or ​nodule ​stippled with microcalcifications
(U/S)​ ​⇒ Suspect malignancy
7-​ Family history of thyroid cancer.

TYPES OF THYROID CANCER:

Remember: Papillary + Follicular are the ​differentiated ​malignant tumors (the cells are ​well formed​), while
anaplastic tumors are called ​undifferentiated ​malignant tumors​.

1. Papillary carcinoma7:
Occurrence -​ ​Female:Male ratio ⇒ 3:1 (more common in females).
- occurs in young age ⇒​ any <20 y/o patient with a single thyroid nodule should be
considered as a case of ​papillary carcinoma until proven otherwise​. ​imp
- ​Most common endocrine cancer is thyroid cancer ​ (and Papillary accounts about​ 85%​ of
thyroid cancers).
-​ ​Appears in early adult life (​Painless​).
- Incidence is increases with exposure to radiation & in familial types.
.papillary thyroid carcinoma ‫ وﻓﯿﻤﺎ ﺑﻌﺪ ﻻﺣﻈﻮا ان ﻫﺎﻻﺷﺨﺎص ﺟﺎﻫﻢ‬low radiation‫ ﺑﺎﻟـ‬acne‫زﻣﺎن ﻛﺎﻧﻮا ﯾﻌﺎﻟﺠﻮن اﻟـ‬

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Which means that if lymphadenopathy is present → very suggestive for malignancy, but you can’t exclude malignancy if
it’s not present.
7
A BRAF mutation is the most common mutation in papillary thyroid cancer and is associated with lymph node
metastases and a higher recurrence rate.

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 Spread and - Lymphatic spread. ​Imp
metastases Any malignancy in the body with lymph nodes involvement → worse prognosis, ​EXCEPT
papillary, the prognosis doesn’t change.
- Metastasizes to lung & bone.

Management total thyroidectomy (because it is multifocal) is the optimal surgical procedure.

Prognosis Usually good prognosis.

2. Follicular carcinoma:
Occurrence - In 30–50 ​year age group (later than papillary).
- Accounts for about ​10% ​of thyroid cancers.

Spread and - Blood spread.​ ​Doesn’t spread to lymph​.

metastases - Metastasizes to lung & bone (functional metastasis, bone and lung starts uptaking iodine
and producing thyroxine by themselve).
- Hürthle cell carcinoma is a clinical variant of follicular carcinoma. It is more likely to be
multifocal and involve lymph nodes. Like follicular carcinoma, it makes thyroglobulin, however
it does not usually take up radioiodine.

Management Treatment consists of total thyroidectomy with preservation of the parathyroids. But
metastasis should be treated by radionuclear radiation containing iodine isotopes so once the
bone metastases uptake it, it’ll burns the cells.

Prognosis Not as good as papillary carcinoma.

3. Medullary carcinoma8:
Origin It’s solid, containing amyloid, nodular tumor that does not take up radioiodine and secretes
calcitonin since Arises from C-Cells in pancreas and adrenals, hence, radioiodine is not good
as investigation or treatment in this condition.
- Accounts for about ​7% ​of thyroid cancers.
- 25% is familial type of medullary carcinoma (Associated with MEN 2a/2b syndrome).
most aggressive in MEN2B patients.

Management - It’s better to do thyroidectomy and remove surrounding lymphs before it progresses.
- Preoperative CT CAP is advised as well as exclusion of pheochromocytoma(MEN2).

Prognosis Prognosis is not good, especially if it's part of MEN ⇒ that's why we screen families.

4. Undifferentiated (Anaplastic):
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MEN IIa: medullary carcinoma, pheochromocytoma, hyperparathyroidism,
MEN IIb: Medullary carcinoma, pheochromocytoma, mucosal neuromas and marfanoid shape

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 Occurrence - Usually in Elderly.
- Accounts for about ​1% ​of thyroid cancers.

Features - Rapidly growing.

-Usually evolves from papillary or follicular neoplasm.
- Locally invasive → causing compression (dyspnea), and may cause Horner's syndrome
(miosis-ptosis-anhidrosis)9

Spread & Cervical lymphadenopathy and pulmonary metastases are common

metastases

Management ​Both resection and chemotherapy ​don’t show any value​, ​external beam radiation​ may be
value. The idea is to relieve compression.

Prognosis the worst; Rarely cured and recurrence is high​.

5. Lymphoma
Occurrence -More common in our part of the world.
- Higher risk in Hashimoto’s.
- Accounts for about ​< 5% ​of thyroid cancers.

Diagnosis Usually diagnosed post-op, but if diagnosed before → send to oncology for treatment.

Management Chemo & radiotherapy.

Investigations:
1 ​Ultrasound​ → ​1st diagnostic method​.
2- ​Fine Needle Aspiration (FNA) ​→ ​ most important method​.
3- ​Percutaneous needle biopsy​ → ​the most cost-effective diagnostic test.
along with ultrasound, Needle biopsy is not as helpful in patients with a history of irradiation to the neck.
Because radiation-induced tumors are often multifocal and a negative biopsy may therefore be unreliable.
4- ​Thyroid uptake scan​ (basically nuclear medicine).
5-​ FNA/Bethesda System​ → ​the main diagnostic method​. ‫اﻟﺪﻛﺘﻮر ﻗﺎل ﻣﺶ ﻣﻬﻢ اﻟﺠﺪول‬.

Indications for Thyroidectomy10

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ّ ‫ اﻟﻌﯿﻦ و ﻓﺘﺤﺎت‬،‫ اﺣﻔﻈﻮﻫﺎ اﻧﻬﺎ ﺛﻼث ﺗﻀﯿﻘﺎت )اﻟﺒﺆﺑﺆ‬،‫ﺳﻨﺪروم ﺗﺠﻲ ﺑﺴﺒﺐ ﺿﺮر ﻋﻠﻰ اﻟﺴﻤﺒﺎﺛﺘﻚ ﺗﺮﻧﻚ‬
(‫اﻟﺘﻌﺮق‬
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Surgery is often the preferred treatment, because it’s more rapid and has more certain control of the disease than
radioiodine.
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U CAN SKIP this part, but we always get asked about the indications in OSCE :).
1- in the presence of a very large goiter or a multinodular goiter ​with ​relatively low radioactive iodine uptake.
2- if there is a suspicious or malignant thyroid nodule.
3- for patients with ophthalmopathy.
4- for the treatment of pregnant patients or children.
5- for the treatment of women who wish to become pregnant within 1 year after treatment.
6- for patients with amiodarone-induced hyperthyroidism.
7- compressive symptoms e.g. Dysphagia, dyspnea and/or hoarseness.

Branchial cyst and fistula: ​​

- Swellings lying laterally in the upper neck may be ​branchial cysts​. ​They are thought to be remnants of the
second and third branchial arches yet often present in young adults. ​The cysts contain opaque fluid with
cholesterol crystals. ​Lymphoid tissue is found in their walls. ​They may become infected and usually require
excision. ​
- Branchial fistula may occur between the skin surface, low in the neck, and the tonsil or lower pharynx
internally. ​Infection often occurs and excision is usually required.

Other cystic swellings:​ ​

Cystic hygroma​ is a rare, benign lymphangioma of the neck, which usually presents in early life.
Complete excision is difficult, leading to frequent recurrence.
Dermoid cysts​ may also occur in the upper neck, usually in the midline or sub​mandibular area, in younger
children. They contain skin appendages unlike sebaceous cysts. ​
Laryngoceles​ occur as a result of herniation of laryngeal mucosa laterally into the neck. They distend with air
during the Valsalva manoeuvre and may become infected. Excision is usually required.

GENERAL CONSIDERATIONS

Thyrotoxicosis: is the clinical condition of presence of high levels of thyroid hormones in Blood by any cause.
Hyperthyroidism:​ is ​over activity​ of the thyroid gland, thus it causes thyrotoxicosis.

Hyperthyroidism Hypothyroidism

1-​GRAVE’S 1-​Surgical removal of thyroid gland

2-​Toxic multinodular goiter 2-​Late ​Hashimoto’s
3-​early​ Hashimoto’s
4-​ single toxic nodule (commonly Follicular
Adenoma).

PARATHYROID SWELLING

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Primary Hyperparathyroidism (PHPT):
Occurrence - ​2​-3 times more​ in females than males.
- Uncommon in children.
- No evidence for geographical variation.

Due to & - In ​90%​ of patients, primary hyperparathyroidism is due to an ​adenoma11, in ​10%​ it results
results in from ​hyperplasia12, and in less than ​1%​ it results from ​parathyroid carcinoma​.
- The most common cause of hypercalcemia.
Most common cause of hypercalcemia in hospitals → malignancy.
Most common cause in community → primary hyperparathyroidism. ​MCQ!
- (all causes of​ high Calcium​ leads to ​high Phosphate​ except this condition → causes​ ​high
Chloride​).

Clinical - In the west 60-70% detected by ​routine screening​.

presentation - Many are ​asymptomatic​.

Clinical 1- Renal stones. ​Due to hypercalcemia

manifestation ‫ﻟﻤﺎ ﯾﺠﯿﻚ ﺑﯿﺸﻨﺖ رﯾﻜﺮﻧﺖ او ﺑﺎﯾﻼﺗﺮال ﺳﺘﻮﻧﺰ اﻓﺤﺺ اﻟﺒﺎراﺛﺎﯾﺮوﯾﺪ‬
s 2- Bone loss and joint pain. ‫اﻟﻌﻈﻢ ​ﯾﻨﻜﺴﺮ ﻣﻦ اﺑﺴﻂ ﺿﺮﺑﺔ‬
3- Abdominal groans.
4- Psychic moans.13
5- Fatigue overtones.
6- Moth Eaten appearance of the skull14.
7- Peptic ulcer

Investigations 1- Serum Calcium.

2- PTH.
3- Serum Phosphate.
4- ​raised Chloride​. ‫ اﻟﻜﻠﻮراﯾﺪ ﻋﺎﻟﻲ واﻟﻔﻮﺳﻔﯿﺖ ﻧﺎﻗﺺ ﻣﻊ اﻟﻬﺎﯾﺒﺮﺑﺎرا‬:‫واﷲ ﯾﺎ ﺷﺒﺎب ﻫﺬا ﺳﺆال ام ﺳﻲ ﻛﯿﻮز ﺣﻠﻮ‬
5- Decreased bone density.
High Serum Calcium + PTH ⇒​ enough to confirm the Dx of 1ry hyperparathyroidism

Management - All symptomatic patients should be treated.

- The aim is to remove all hyper​active parathyroid tissue.
In adenoma →​ remove the enlarged gland​.
In hyperplasia → ​remove 3.5 glands​, leave only half a gland for the patient to maintain the
function.

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In adenoma, usually only 1 parathyroid gland is enlarged.
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In hyperplasia, ​all 4 glands​ are usually affected.
/: ‫ ﺑﺲ‬increased parathyroid hormone ‫ ​ﻛﺎﻧﻮا ﯾﺮوﺣﻮن ﻟﻠﺴﺎﯾﻜﺎﺗﺮي وﯾﻠﻘﻮن ﻣﺮﺿﻰ ﻣﻨﻮﻣﯿﻦ وﺳﺒﺐ ﺗﻨﻮﯾﻤﻬﻢ ﻛﺎن‬13
14
​ ​multiple small endosteal lucent lesions or holes, often with poorly defined margins, with sparing of the cortex.
8
Thyroglossal cyst:
Pathophysiology The thyroid gland begins its embryological development in the tongue base and as it
descends a duct forms and then gets obliterated. A cyst may develop with improper
obliteration.

Note If we see a lump, how can we tell if it is a thyroid lump? Ask the patient to swallow. If it
doesn’t move with swollowing then it is not thyroid disease (could be dermoid cyst, lipoma,
lymph Node). If it moves then it is one of two: Thyroid lump “goiter” Thyroglossal cysts.
Then you ask the patient to stick his tongue out and if the lump moves then it is a
thyroglossal cyst. Because Thyroglossal cysts extend to the tongue.

Treatment surgical excision

Pics

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Recall : THYROID
1.Identify the following structures:​1. Pyramidal lobe 2. Right lobe 3. Isthmus 4. Left lobe
2.define the arterial blood supply to the thyroid:
a. Superior thyroid artery ( first branch of the external carotid artery)
b. Inferior thyroid artery (branch of the thyrocervical trunk) (IMA artery rare​)
3.What is the venous drainage of the thyroid?
1. Superior thyroid vein 2. Middle thyroid vein 3. Inferior thyroid vein
4.Name the lymph node group around the pyramidal thyroid lobe?​ Delphian lymph node
group
5.What is the thyroid isthmus? ​Midline tissue border between the le and right thyroid lobes
6.Which ligament connects the thyroid to the trachea?​ Ligament of Berry (remember mazen
berry)
7.Which paired nerves must be carefully identi ed during a thyroidectomy?
Recurrent laryngeal nerves,behind the cricothyroid muscle; damage one causes hoarseness, if
bilateral = airway obstruction .
8.What is TRH?​ Thyrotropin-Releasing Hormone released from the hypothalamus;causes release
of TSH …… ​whats is it ?​ Thyroid-Stimulating Hormone released by the anterior pituitary; causes
release of thyroid hormones from the thyroid..​ What are they?​ T3(active) and T4(levothyroxine).
9.What is the di erential diagnosis of a thyroid nodule?
Multinodular goiter /Hyperfunctioning adenoma/ Cyst/ thyroiditis/ Carcinoma/lymphoma
10.What are the indications for a scintiscan?​1. Nodule with multiple “nondiagnostic” FNAs
with low TSH 2. Nodule with thyrotoxicosis and low TSH
11.In evaluating a thyroid nodule, which of the following suggest thyroid carcinoma:​ History?
1. Neck radiation 2. Family history (thyroid cancer, MEN-II) 3. Young age 4. Male>female
Signs?
1. Single nodule 2. Cold nodule 3. Increased calcitonin levels 4. Lymphadenopathy 5. Hard, immobile nodule
Symptoms?
1. Voice change (vocal cord paralysis) 2. Dysphagia 3. Discomfort (in neck) 4. Rapid enlargement
12.What is the most common cause of thyroid enlargement?​ Multinodular goiter
13.What are indications for surgery with multinodular goiter?​ Cosmetic deformity, compressive symptoms, cannot rule out
cancer
14.Anaplastic Carcinoma What is it also known as?
Undifferentiated cancer arising in 75% of previously differentiated thyroid cancers (most commonly, follicular carcinoma)
15.How can the differences between etiologies of ACUTE and SUBACUTE thyroiditis be remembered?
Alphabetically: A before S, B before V (i.e., Acute before Subacute and Bacterial before Viral, and thus: Acute Bacterial and
Subacute Viral)
16.What are the common causative bacteria in acute suppurative thyroiditis?​ Staph and streptococcus
17.What are the two types of chronic thyroiditis?​ 1. Hashimoto’s thyroiditis 2. Riedel’s thyroiditis (subacute sometimes)

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1. A 30-year old female presents with pain in the right forearm. She has a long history of bone aches,
heartburn & easy fatigue. She also had a stone removed from her left ureter 5 years ago. Lab tests
revealed a serum calcium level of 14.3 mg/dl and a phosphate level of 2.4 mg/dl. Diagnosis:
A. Hyperthyroidism
B. Adrenal insufficiency
C. Hyperparathyroidism
D. Familial hypocalciuric hypercalcemia

2. The most common pathology of the parathyroid glands is:

A. Hyperplasia
B. Adenoma
C. Carcinoma
D. None of the above

3. Which of these manifestations indicate advanced hyperparathyroidism?

A. Renal stones
B. Bone pain
C. Fatigue
D. Abdominal pain

4. Which of the following is NOT true about hyperparathyroidism?

A. Common in children
B. Affects females more than males
C. Many are asymptomatic
D. All have advanced bone disease

5. Which of the following is true about hyperparathyroidism?

A. PHP is under diagnosed in Saudi Arabia
B. Patients are not diagnosed early
C. t should be suspected in patients with bilateral or recurrent renal stones
D. All of the above

6.The following are useful in the diagnosis of hyperparathyroidism, except:

A. High PTH
B. Low serum phosphate
C. High serum chloride
D. High serum phosphate

7. The most common type of thyroid tumors is:

A. Papillary carcinoma
B. Follicular carcinoma
C. Lymphoma
D. Medullary carcinoma

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8. A thyroid tumor arising from C-cells that is related to MEN syndrome is:
A. Papillary carcinoma
B. Follicular carcinoma
C. Lymphoma
D. Medullary carcinoma

9. Which thyroid cancer is more common in the middle east?

A. Papillary carcinoma
B. Follicular carcinoma
C. Lymphoma
D. Medullary carcinoma

10. Thyroid lymphomas are:

A. Usually diagnosed post-operatively
B. Treated by chemo-radiotherapy
C. Rarely curable
D. A & B

11. Papillary carcinomas:

A. Appear in early adult life
B. Spread hematogenously
C. Have a bad prognosis
D. Are rapidly growing, very aggressive tumors

12. Follicular carcinomas:

A. Are associated with MEN syndrome
B. Spread through lymphatics
C. Have a good
D. Differentiation between benign & malignant forms is difficult

13. All the following are superficial neck swellings EXCEPT:

A. Branchial cyst
B. Sebaceous cyst
C. Lipoma
D. Neurofibromatosis

14. The most common midline single neck swelling is:

A. Pharyngeal pouch
B. Dermoid cyst
C. Laryngocele
D. Thyroglossal cyst

15. The third postoperative day following thyroidectomy a patient c/o tingling of her finger tips and is
found to have serum calcium of 1 mmol/l/. The next step in treatment should be:
A. Careful observation until the Calcium level increases
B. Administration of dihydrotachysterol
C. Administration of 1,25(OH) 2D (Calcitriol)

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 D. Administration of calcium gluconate by slow intravenous drip

16. Medullary Thyroid Carcinoma:

A. Is a tumor of Parafollicular C cells
B. Produces thyroxine as the principal hormone
C. Are TSH dependent
D. T3 act as a tumor marker

17. What is the least likely cause of Hypercalcemia?

A. Metastatic tumor
B. Acute pancreatitis
C. Hyperparathyroidism
D. Vit. D deficiency

18. The approach to patient with thyroid nodule includes the following except:
A. Thyroid scan.
B. Fine needle aspiration.
C. Ultrasonography.
D. Calcitonin level.

Answers:
1- C
2- B
3- B
4- A
5- D
6- D
7- A
8- D
9- C
10- D
11- A
12- D
13- D
14- D
15- D
16- A
17- D
18- D

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