Fellowship of the Royal College of Surgeons (FRCS) Specialty Surgery: Plastics, ENT, Paediatric, Cardiothoracic and Neurosurgery Syllabus

Which nerve is at risk during thyroidectomy, what does injury cause, and its relation to the inferior thyroid artery?

The recurrent laryngeal nerve (branch of vagus). It runs in the tracheo-oesophageal groove near/around the inferior thyroid artery. Unilateral injury causes hoarseness (ipsilateral cord paralysis); bilateral injury can cause airway obstruction requiring tracheostomy. The external branch of the superior laryngeal nerve (near superior pole vessels) supplies cricothyroid — injury weakens high-pitched phonation.

Outline the biochemical pattern of primary hyperparathyroidism.

Elevated parathyroid hormone (PTH), high serum calcium, low serum phosphate, and raised urinary calcium excretion. Most commonly caused by a solitary parathyroid adenoma. Classic symptoms: 'stones, bones, abdominal groans, and psychiatric moans'.

Compare conductive and sensorineural hearing loss including a Rinne/Weber bedside pattern.

Conductive (outer/middle ear pathology): Rinne negative (bone > air) on affected side; Weber lateralises to the affected ear. Sensorineural (cochlea/CN VIII): Rinne positive (air > bone) bilaterally; Weber lateralises to the better (unaffected) ear.

What is cholesteatoma and why is it dangerous?

Cholesteatoma is keratinising squamous epithelium trapped in the middle ear/mastoid, forming an expanding, locally destructive sac. It erodes bone (ossicles, semicircular canals, facial nerve canal, tegmen), causing conductive hearing loss, foul discharge, and potential complications: facial palsy, labyrinthine fistula, meningitis, intracranial abscess. Treatment is surgical (mastoidectomy).

Describe Epley/canalith repositioning indication and the pathology of BPPV.

Benign paroxysmal positional vertigo (BPPV) is caused by displaced otoconia (canaliths), usually in the posterior semicircular canal, provoking brief rotational vertigo with positional change. Diagnosed with the Dix-Hallpike manoeuvre and treated with the Epley repositioning manoeuvre.

List the management steps for anterior epistaxis from Little's area (Kiesselbach's plexus).

First aid: lean forward, pinch the soft cartilaginous part of the nose for 10–15 minutes. If continuing: topical vasoconstrictor and direct cautery (silver nitrate) of the bleeding point. If uncontrolled: anterior nasal packing. Posterior bleeds may need posterior packing/balloon and consideration of sphenopalatine artery ligation/embolisation.

Which artery is the usual culprit in severe posterior epistaxis, and how is it controlled surgically?

The sphenopalatine artery (a terminal branch of the maxillary artery, from the external carotid). Refractory posterior bleeds are managed by endoscopic sphenopalatine artery ligation or radiological embolisation.

What is the immediate management algorithm for an acute airway emergency (e.g., impending obstruction)?

Follow ABC: high-flow oxygen, optimise positioning, call senior anaesthetic/ENT help early. Adjuncts and definitive airway as needed: bag-mask, supraglottic airway, endotracheal intubation. If 'cannot intubate, cannot oxygenate': emergency front-of-neck access — cricothyroidotomy (surgical or needle) — through the cricothyroid membrane.

Name and briefly describe four common neonatal surgical emergencies.

Oesophageal atresia/tracheo-oesophageal fistula (drooling, cannot pass NG tube, coiled tube on X-ray). Congenital diaphragmatic hernia (respiratory distress, scaphoid abdomen, bowel in chest). Gastroschisis/exomphalos (anterior abdominal wall defects). Malrotation with midgut volvulus (bilious vomiting — a surgical emergency). Also necrotising enterocolitis and Hirschsprung's disease.

What is the cardinal red-flag sign of malrotation/midgut volvulus in a neonate, and the diagnostic test?

Bilious (green) vomiting in a neonate is malrotation with volvulus until proven otherwise — a surgical emergency due to risk of midgut ischaemia. Urgent upper GI contrast study is the gold standard, classically showing an abnormal duodenojejunal flexure position and a 'corkscrew' appearance.

Contrast the typical presentation of hypertrophic pyloric stenosis with that of duodenal atresia.

Pyloric stenosis: 3–6 week old (more common in firstborn males), non-bilious projectile vomiting, palpable 'olive' mass, hypochloraemic hypokalaemic metabolic alkalosis. Duodenal atresia: presents in first day with bilious vomiting (if distal to ampulla), 'double bubble' sign on X-ray, associated with Down syndrome.

State the Holliday-Segar formula for paediatric maintenance fluid (the 4-2-1 rule).

$4\,\text{mL/kg/h}$ for the first 10 kg, plus $2\,\text{mL/kg/h}$ for the next 10 kg (11–20 kg), plus $1\,\text{mL/kg/h}$ for each kg above 20 kg. Example: a 25 kg child = $40 + 20 + 5 = 65\,\text{mL/h}$.

How is the circulating blood volume of a neonate/child estimated, and what bolus is used in paediatric resuscitation?

Estimated blood volume: neonate ~$80\text{–}90\,\text{mL/kg}$, infant/child ~$70\text{–}80\,\text{mL/kg}$. Resuscitation fluid bolus: $10\text{–}20\,\text{mL/kg}$ of isotonic crystalloid, reassessing after each bolus.

Why are paediatric patients more vulnerable to fluid and temperature derangement than adults?

Children have a higher surface-area-to-volume ratio (greater insensible/heat loss), higher total body water as a proportion of weight, higher metabolic rate, immature renal concentrating ability, and limited glycogen reserves — making them prone to rapid dehydration, hypothermia, and hypoglycaemia.

Which coronary arteries are most commonly grafted in CABG, and what is the preferred conduit?

Commonly grafted: left anterior descending (LAD), circumflex (and obtuse marginal) and right coronary artery (or its branches). The left internal mammary (thoracic) artery (LIMA) to the LAD is the conduit of choice due to superior long-term patency; saphenous vein and radial artery are also used.

What ECG and biomarker findings distinguish STEMI, NSTEMI, and unstable angina?

STEMI: ST-segment elevation (transmural ischaemia) with raised troponin. NSTEMI: no ST elevation (may have ST depression/T-wave changes) but raised troponin. Unstable angina: ischaemic symptoms/ECG changes possible but troponin normal (no myocardial necrosis).

List the classic triad of symptoms of severe aortic stenosis and its prognostic significance.

Syncope, Angina, and Dyspnoea (heart failure) — 'SAD'. Once symptomatic, untreated severe aortic stenosis carries a poor prognosis (average survival of roughly 2–3 years for heart failure, 3 for syncope, 5 for angina), prompting aortic valve replacement.

Contrast aortic stenosis and mitral regurgitation murmurs.

Aortic stenosis: ejection systolic murmur, loudest at the right upper sternal edge, radiating to the carotids, with a slow-rising pulse and narrow pulse pressure. Mitral regurgitation: pansystolic murmur at the apex radiating to the axilla, with a displaced apex beat in chronic cases.

Compare mechanical and bioprosthetic heart valves.

Mechanical: very durable (last decades) but require lifelong anticoagulation (warfarin) due to thrombogenicity — favoured in younger patients. Bioprosthetic (tissue): no long-term anticoagulation needed but limited durability (~10–15 years) with structural degeneration — favoured in older patients or where anticoagulation is contraindicated.

What are the principal components and function of the cardiopulmonary bypass (CPB) circuit?

Venous cannula drains blood to a reservoir, an oxygenator performs gas exchange (oxygenation + CO2 removal), a heat exchanger controls temperature, a roller/centrifugal pump returns oxygenated blood to the arterial cannula (usually aorta). It diverts blood from the heart and lungs to allow a bloodless, motionless operative field while perfusing the body.

What is cardioplegia and how does it protect the myocardium during CPB?

Cardioplegia is a high-potassium solution delivered to the coronaries to arrest the heart in diastole, abolishing electromechanical activity and dramatically reducing myocardial oxygen demand. Combined with hypothermia, it protects the arrested heart from ischaemic injury during cross-clamping.

Why is heparin given before CPB and how is it reversed?

Heparin (systemic anticoagulation, targeting an activated clotting time typically $> 400\text{–}480\,\text{s}$) prevents clotting within the bypass circuit's foreign surfaces. After weaning from CPB, it is reversed with protamine sulfate.

Name three indications for lung resection / common thoracic surgery procedures.

Lobectomy or pneumonectomy for non-small cell lung cancer; decortication/drainage for empyema; pleurodesis or bullectomy for recurrent/secondary pneumothorax. Wedge resection is used for peripheral nodules or diagnostic biopsy.

What are the components of the Glasgow Coma Scale and the range of scores?

Eye opening (1–4), Verbal response (1–5), and Motor response (1–6), giving a total range of 3 (deepest coma) to 15 (fully alert). Severe TBI: GCS $\leq 8$; moderate 9–12; mild 13–15. GCS $\leq 8$ generally indicates need for definitive airway protection.

State the Monro-Kellie doctrine and its implication for intracranial pressure.

The cranium is a fixed-volume box containing brain, blood, and CSF. An increase in one component (e.g., a haematoma or oedema) must be compensated by a decrease in another (CSF/venous blood displacement) to keep ICP stable. Once compensation is exhausted, small volume increases cause steep ICP rises and herniation.

Define cerebral perfusion pressure (CPP) and its target in TBI.

$\text{CPP} = \text{MAP} - \text{ICP}$ (mean arterial pressure minus intracranial pressure). Target CPP in TBI is typically $60\text{–}70\,\text{mmHg}$; ICP is generally kept $< 20\text{–}22\,\text{mmHg}$ to maintain adequate cerebral blood flow and avoid ischaemia.

Contrast extradural and subdural haematoma on CT and typical cause.

Extradural: biconvex (lentiform) hyperdensity that does not cross suture lines; classically from middle meningeal artery rupture after temporal trauma, with a 'lucid interval'. Subdural: crescent-shaped (concave) collection that crosses suture lines; from bridging vein rupture; common in elderly/alcoholics, may be acute or chronic.

What is the classic presentation of subarachnoid haemorrhage and the first-line investigation?

Sudden-onset severe 'thunderclap' headache ('worst headache of life'), often with neck stiffness, photophobia, and decreased consciousness; commonly from a ruptured berry aneurysm. First-line investigation is a non-contrast CT head; if negative and clinical suspicion remains, lumbar puncture (after ~12 h) looking for xanthochromia.

What grading scales are used for subarachnoid haemorrhage, and what does vasospasm cause?

Clinical severity is graded by the World Federation of Neurosurgical Societies (WFNS) or Hunt and Hess scales; CT blood load by the Fisher scale. Delayed cerebral vasospasm (peak days 4–14) causes delayed ischaemic deficits and is mitigated with the calcium-channel blocker nimodipine.

Compare the most common primary intra-axial brain tumours in adults and children.

Adults: glioblastoma (grade IV astrocytoma) is the most common malignant primary; metastases are the most common brain tumours overall. Meningioma is the most common extra-axial (benign) tumour. Children: posterior fossa tumours predominate — pilocytic astrocytoma and medulloblastoma.

Define hydrocephalus and contrast communicating with non-communicating types.

Hydrocephalus is excess CSF accumulation causing ventricular dilatation and raised ICP. Non-communicating (obstructive): blockage within the ventricular system (e.g., aqueduct stenosis, tumour) preventing CSF flow to the subarachnoid space. Communicating: impaired CSF reabsorption at the arachnoid granulations or overproduction, with the ventricular system patent.

What are the CSF diversion options for hydrocephalus and a key complication of each?

Ventriculoperitoneal (VP) shunt — most common; complications include blockage, infection, and over-/under-drainage. Endoscopic third ventriculostomy (ETV) — for obstructive hydrocephalus, avoids hardware; risk of closure/failure and basilar artery injury. External ventricular drain (EVD) — temporary; risk of ventriculitis and over-drainage.