View Answer

D

2. A 50-year-old hypertensive man has definitive biochemical evidence of a pheochromocytoma. Computed tomography (CT) scan and magnetic resonance imaging (MRI) do not reveal any abnormalities, and m-iodobenzylguanidine scanning is not readily available. What should be the next step in the management of this patient?

A Abdominal exploration

B Continued clinical observation

C Mediastinoscopy

D Selective venous sampling

E Mediastinal exploration

View Answer

D

3. A 55-year-old woman with progressive but episodic muscle weakness is diagnosed as having myasthenia gravis. Her chest radiograph is normal and reveals no evidence of mediastinal mass or tumor. What is the most definitive treatment that can be offered this patient?

A Prednisone

B Neostigmine

C Thymectomy

D Plasmapheresis

E Atropine

View Answer

C

4. A first-degree relative of a patient found to have advanced medullary carcinoma of the thyroid gland is referred for further evaluation. Which screening measure is the choice for detection of medullary thyroid pathology?

A Careful physical examination

B Serum calcitonin level

C Stimulated serum calcitonin level (calcium and pentagastrin)

D Gastrin level

E Carcinoembryonic antigen (CEA) level

View Answer

C

5. If a first-degree relative of a patient with MEN-2 A syndrome is found to have medullary pathology requiring surgical exploration of the thyroid gland, what should the preoperative screening include?

A Serum cortisol level

B Fasting glucose and insulin

C CT scan of the head

D Urinary aldosterone and renin

E Urinary vanillylmandelic acid and metanephrines

View Answer

E

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6. A 60-year-old female patient has a workup for episodic symptoms of palpitations, nervousness, and bizarre behavior, all of which tend to occur during fasting states. Biochemically, she is diagnosed as having an insulinoma. What is the best choice for localizing this tumor?

A CT scan

B MRI

C Selective arteriography

D Percutaneous catheterization of the portal vein with selective venous sampling

E Surgical exploration and intraoperative ultrasound

View Answer

E

7. A 55-year-old female patient is evaluated for new onset of diabetes mellitus. Her medical history is largely unremarkable. Her physical examination is unrevealing except for the presence of an erythematous skin rash. Her further evaluation should include an investigation of the possibility of which of the following?

A Insulinoma

B Glucagonoma

C Gastrinoma

D Carcinoid tumor

E Pancreatic cholera

View Answer

B

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Answers and Explanations

• 1. The answer is D (Chapter 16, I D 2 e [4] [b] [ii]). Postoperative bleeding after thyroidectomy can cause airway compromise due to tracheal compression. The first step should be to open the wound to evacuate the hematoma, followed by a return to the operating room to control the bleeding site. Attempts to perform either endotracheal intubation or tracheostomy may be difficult until the external compression of the hematoma is relieved.

• 2. The answer is D (Chapter 16, II G 5 d). Although 90% of pheochromocytomas are located in the adrenal glands, they can occur in any tissue that is derived from neuroectoderm. When computed tomography (CT) scan and magnetic resonance imaging (MRI) do not identify a tumor, m-iodobenzylguanidine scanning can be helpful; however, this is not always available. Selective measurements of catecholamines drawn at various levels from the vena cava and its major branches should be obtained before surgical exploration.

• 3. The answer is C (Chapter 16, IV C 3 b). Myasthenia gravis is an autoimmune disease of neuromuscular transmission that causes skeletal muscle weakness. Parasympathomimetic drugs have been found to improve muscle strength in these patients. Prednisone has also been used with some success because of the autoimmune nature of this disease. Plasmapheresis may be effective in preparing the patient preoperatively. The treatment of choice for all forms of myasthenia, except purely ocular, appears to be thymectomy. An increased percentage of patients have permanent remission. The response to medication is improved in patients who do not achieve a complete remission.

• 4. The answer is C (Chapter 16, I F 5 c [2] [c]). All first-degree relatives of patients with medullary carcinoma of the thyroid gland should be screened for this disorder because it can occur in a familial pattern. Physical examination of the thyroid gland should be performed for the detection of any nodules. An increased serum calcitonin or an increased stimulated serum calcitonin test will also indicate underlying medullary pathology, either hyperplasia or carcinoma. The stimulated tests will detect disease at an earlier, more curable stage. Increased gastrin levels are associated with Zollinger-Ellison syndrome and are not part of this multiple endocrine adenomatosis (MEN) type 2 syndrome. Carcinoembryonic antigen (CEA) is elevated in some gastrointestinal malignancies.

• 5. The answer is E (Chapter 16, II G 4 a; Chapter 17, I B 2). Medullary carcinoma of the thyroid gland may present as a sporadic or familial form associated with MEN type 2A or 2B. Both are associated with pheochromocytomas. If a pheochromocytoma is present, it should be diagnosed and treated first to avoid the morbidity of cervical exploration in a patient with untreated pheochromocytoma. Urinary vanillylmandelic acid and metanephrines should be evaluated preoperatively.

• 6. The answer is E (Chapter 17, II B 4 a [2]). The patient has had a definitive biochemical diagnosis of insulinoma. These tumors can be present anywhere in the pancreas. Because they are usually small in size, arteriography, CT, and MRI are less sensitive than they would be for larger tumors. With careful surgical exploration and intraoperative ultrasound, approximately 90% of these tumors can be localized at the time of surgery.

• 7. The answer is B (Chapter 17, II E 1). Glucagon-producing tumors of the pancreas secrete glucagon in large amounts. Patients tend to present with new onset of diabetes mellitus (hyperglycemia). Affected individuals also characteristically have a migratory erythematous skin rash.

Study Questions for Part VI(head and neck)

Directions: Each of the numbered items in this section is followed by several possible answers. Select the ONE lettered answer that is BEST in each case.

1. A 35-year-old man presents with left unilateral tinnitus and mild left sensorineural hearing loss. Which of the following statements is true?

A Such signs and symptoms are common and should not be worked up unless they worsen.

B An MRI scan should be obtained, but gadolinium enhancement and its attendant risks are not necessary.

C Brain stem evoked response audiometry is likely to be normal.

D The patient should be assumed to have an acoustic neuroma until proven otherwise.

E Conditions that cause such problems do not affect the other ear.

View Answer

D

Questions 2–3

A 35-year-old man has right-sided serous otitis media and a right upper neck mass.

2. It is most important to evaluate this patient for which of the following?

A Cancer of the right ear

B Cancer of the right tonsil

C Cancer of the right maxillary sinus

D Cancer of the nasopharynx

E Hodgkin's lymphoma

View Answer

D

3. Which of the following will be the primary treatment for this tumor?

A Local excision to negative margins

B Wide local excision and radical neck dissection

C Neoadjuvant chemotherapy followed by resection of residual tumor

D Unilateral radiotherapy with combined chemotherapy

E Bilateral radiotherapy

View Answer

E

Questions 4–5

A 65-year-old man is found to have a small invasive squamous cell carcinoma of the right vocal cord. The right vocal cord is paralyzed, and a lymph node in the right anterior neck is 4 cm in diameter.

4. The stage of the tumor is which of the following?

A T2N1

B T2N2a

C T3N1

D T3N2a

E T4N3

View Answer

D

5. Optimal treatment of the primary tumor should include which of the following?

A Total laryngectomy

B Vertical hemilaryngectomy

C Supraglottic (horizontal) laryngectomy

D Right cordectomy

E Chemotherapy

View Answer

A

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Questions 6–7

A 55-year-old woman presents with complaint of a mass overlying the angle of the right mandible. She says the mass has been slowly enlarging over the past 2–3 years and that the mass is painless. On physical examination, it is firm and overlies the angle of the right mandible and the area between the angle and the tragus of the ear. Neurologic examination of the head and neck is completely normal.

6. Which of the following does this mass most likely represent?

A Mucoepidermoid cancer of the parotid gland

B Acute parotitis

C Benign mixed tumor of the parotid gland (pleomorphic adenoma)

D Malignant mixed tumor of the parotid gland

E Hemangioma of the parotid gland