Parathyroid pearls
Reviewed by Suzanne Jervis

This article serves to deliver some pearls of wisdom in parathyroid surgery for the ‘low volume parathyroid surgeon’. They have been divided into those relating to the preoperative diagnosis, imaging and localisation techniques and surgical difficulties. Recognised sources of error in diagnoses range from the non-suppressed parathyroid hormone level, inadequate volume of urine collection and normocalcaemic primary hyperparathyroidism. With respect to sestamibi scans, rapid washout of the technetium from the parathyroid glands can occur before the second phase of the image is acquired, giving a false negative result. Ultrasound can also fail to detect deep adenomas or limited experience of the sonographer may lead to reports suggestive of a single posterior hypoechoic thyroid nodule (in an otherwise normal gland) and a well-intentioned FNAC can suggest a follicular lesion, a common misdiagnosis from parathyroid tissue as they are notoriously difficult to diagnose on cytopathology. They then describe some surgical tips that make for interesting reading. One such tip is to scan the patient while on table, immediately prior to the incision. A further tip involves ensuring a sufficiently deep enough dissection, especially in the context of an overly descended superior adenoma. ‘Hiding places’ are described by the authors, but also the use of performing bilateral IJV PTH assays to identify the side of the neck with the hyper functioning tissue, looking for a difference of between 5 and 10%. This article is supported by intra-operative, radiographic and line drawn images to further aid the readers’ understanding of the issues at large. This clearly may be no news to some parathyroid surgeons and of little benefit, having determined these pitfalls for themselves, but maybe for the younger, less experienced parathyroid surgeon, it may just help.

Nuances in parathyroid evaluation and management.
Terris DJ, Duke WS.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2016:27(3):175-81.