preoperative and intraoperative
localization of abnormal parathyroid glands
Rummana Aslam, MD
Anatomic distribution of
Upper gland in order of frequency,
– the cricothyroid junction; the dorsum of the upper pole of
the thyroid; and the retropharyngeal space
– at the lower pole of the thyroid and the thymic tongue;
rarely in the upper, the lateral neck, or the mediastinum
Subcapsular located within the surgical capsule of the thyroid
Extracapsular in posteriorior or anterior mediastinum
Supernumerary, fused, and intrathyroidal parathyroids
Wang,. Ann Surg Mar 1976
“The anatomy of primary
Single gland enlargement (adenoma) 218/273 patients (80%);
Hyperplasia of all identified parathyroid glands 42/273 patients
Two adenomas :7 patients (2.6%).
Biochemical evidence of the disease with normal glands at
neck exploration: 7 patients (2.6%)
Ectopic right superior gland adenomas (mean size 2.6 cm) 39%
Ectopic left superior gland adenomas (mean size 2.62 cm) 36%.
Intrathyroid superior adenomas: none.
Intrathyroid inferior adenomas: five of 223 (2%)
Inferior gland adenomas within the thymus
Failure rate of cervical exploration (4%): attributed to
mediastinal adenomas, and a second adenoma, and incorrect
Thompson NW. Surgery. 1982 Nov.
48 patients with neck exploration for parathyroid adenomas
Thirty-two of the 48 patients (67%) had successful unilateral
16 patients underwent bilateral exploration, and 7/16 had no
reduction in PTH level
Of these seven, five were found to have a second adenoma and two
had slow metabolism of hormone with no additional abnormal tissue
In 5 of the 16 patients, bilateral exploration was performed for
Four additional patients underwent bilateral exploration for improved
exposure or negative results on localization tests.
Conclusions: 70% rate of unilateral neck exploration
Intrinsic 15% rate of multinodular primary hyperparathyroidism
combined with limited results of preoperative localizing techniques
Moore, Francis D. Jr. Annals of surgery 1999
Hajioff d., (2004) Clin. otolarygol
“accuracy of ultrasonography, sestamibi scintigraphy and their
combination in 48 cases of primary hyperparathyroidism”
Ultrasound had a sensitivity of 64.3%
and positive predictive value (PPV) of 100% (81.5–100) for correct
Sestamibi had a sensitivity of 83.3% (69.8–92.5) and PPV of 87.1%
The simple combination of ultrasound with sestamibi had a sensitivity of
82.1% (63.1–93.9) and a PPV of 92.0% (74.0–99.0): little different
from sestamibi alone.
Hajioff d., (2004) Clin. otolarygol
Twenty-three consecutive patients underwent 24 operations
for primary hyperparathyroidism.
– preoperative technetium 99m-sestamibi planar scintigraphy,
– preoperative administration of 7.5 mg/kg methylene blue initiated
within 60 minutes of surgical incision, and surgical neck
exploration supervised by a single surgeon.
RESULTS: All patients were cured of hypercalcemia.
– Sensitivity for sestamibi and for methylene blue staining
was 76% and 79%, respectively.
– Specificity for sestamibi and for methylene blue was 98%
and 93%, respectively.
– Agreement between sestamibi and methylene blue was
Orloff, Lisa A. MD., Larygoscope 2001
Intraoperative PTH assay
• Miami criterion (>50% drop from highest baseline IOPTH level at 10
minutes after excision)
• criterion 1 (>50% drop from preincision IOPTH level at 10 minutes)
• criterion 2 (>50% drop from highest baseline IOPTH level at 10
minutes and final IOPTH level within the reference range)
• criterion 3 (>50% drop from highest baseline IOPTH level at 10
minutes and final IOPTH level less than the preincision value)
• criterion 4 (>50% drop from highest baseline IOPTH level at 5
minutes), and criterion 5 (>50% drop from preexcision IOPTH level at
• Conclusions: Satisfying criterion 2 had a high operative success but
resulted in additional unnecessary surgical exploration. Criterion 1
was better at predicting postoperative normocalcemia than criterion
• Chiu, Bill MD, Arch of Surgery, May 2006
“The adenoma is confined by the thyroid capsule and mimics the
shape of the thyroid pole.
This conformation can often be confirmed on anterior and lateral
pinhole views using a dual-isotope technique. In these cases,
109 patients identified, 10 were diagnosed with parathyroid
hyperplasia and 99 with parathyroid adenomas
Of the 99 adenomas, 16 (16%) were in subcapsular locations.Three
patterns as related to thyroid
– (1) focal convex distortion of the posterior aspect of the thyroid, 11/16
– (2) polar lentiform configuration, and 3/16
– (3) compression of the posterior thyroid parenchyma.2/16 Kraas J.
Clinical Nuclear Medicine. April 2005.
Kraas J. Clinical Nuclear Medicine. April 2005
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