Neck Exploration for Parathyroidectomy: The Hidden Parathyroid
Overview of elusive glands and surgical decisions
What happens when blood tests clearly show an overactive parathyroid gland, but scans can’t identify where the abnormal gland is?
This case of parathyroidectomy and neck exploration shows how surgical experience and careful decision-making can help uncover an abnormal gland hiding in an unusual location.
When scans don’t show the abnormal gland
Occasionally, despite blood tests showing obvious parathyroid disease, scans don’t show up any abnormal or over functioning parathyroid glands.
In this case, we need to perform a neck exploration, otherwise known as a cervical exploration. This requires the surgeon to carefully dissect out each of the four parathyroid glands, and make a clinical judgement on which glands to remove.
This is a true ‘Goldilocks’ moment, where we try not to remove too much parathyroid tissue, as this can lead to overtreatment, but also making sure we remove enough, so that we don’t undertreat!
Why getting it right the first time matters
Redo surgery is always difficult.
We really want Parathyroidectomy to go right the first time.
This can be aided by adjuncts such as measuring parathyroid hormone during the Parathyroidectomy procedure.
However, even this is not always successful.
Every surgeon goes through a journey of making sense of this, and there isn’t always a straightforward answer.
The joy of parathyroid surgery is not only how technical the operation is, but also the very careful decision making process during surgery.
A challenging case
Let’s go through an example of a challenging case in this very active 70-year-old lady.
She came to see me, referred directly by an endocrinologist, with dangerously high calcium.
Moreover, she required Cinacalcet to control it. Parathyroidectomy may be considered if persistent elevations occur.
All standard imaging (USS and Nuclear Medicine) performed was not particularly helpful.
Interestingly, a nodule was picked up in the right thyroid lobe, which did not look suspicious on Ultrasound. We performed a parathyroid CT, which again, only picked up this incidental nodule.
CT scan demonstrating lesion in right thyroid gland.
Proceeding with surgery
Surgery could not wait, and we needed to proceed with surgery to look at all four parathyroid glands.
During surgery, we found THREE normal parathyroid glands (marked with a blue stitch in the pictures).
On the left, there were two normal glands in the usual position.
Intra-operative photo of the LEFT thyroid lobe, lifted upwards, showing two normal parathyroid glands.
However, on the right, there was only one parathyroid gland, which was only slightly enlarged.
Intra-operative photo of the RIGHT thyroid lobe, lifted upwards, showing only a single, normal superior (upper) parathyroid gland.
Where experience and surgical intuition comes in
Indeed, this is where experience and surgical intuition come in during Parathyroidectomy.
Knowing that there was a nodule INSIDE the right thyroid gland, and a missing parathyroid gland on this side – what if the nodule was indeed the enlarged parathyroid gland, hiding inside the thyroid gland?
I proceeded to perform a hemithyroidectomy – removal of the right half of the thyroid gland, the right upper parathyroid gland and the thymus.
Post-operative photo of Right thyroid lobe, Right parathyroid gland and thymic tissue.
What we found
What we found was very Interesting!
There was indeed a parathyroid adenoma hiding inside the parathyroid gland!
However, we also found three small parathyroid cancers; 0.6, 0.8 and 1mm (papillary thyroid carcinoma).
The outcome
After surgery, her blood results show a normal Calcium.
She was cured not only of her hyperparathyroidism, but also of her hidden parathyroid cancer!
Concerned about a thyroid or parathyroid condition?
If you have been diagnosed with a thyroid or parathyroid condition, or would like to discuss your treatment options, you can arrange a consultation with Mr Rajiv Dave.
