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Diagnosis and Surgical Treatment

By Edgar B. Galloway, III, MD

The Colorado Otolaryngology Associates physician staff consists of eight otolaryngology head that number has distinct advantages in that it allows the surgeons to fi nd areas of particular interest within our specialty that we are able to concentrate on – a specialty within a specialty if you will. For me, one of those areas has been surgery of the thyroid and parathyroid gland.

Hyperparathyroidism is a common endocrine condition caused by excessive and uncontrolled secretion of parathyroid hormone (PTH) by the parathyroid glands. Increased levels of PTH have effects on bone, the GI tract, and the kidneys resulting in elevated serum calcium levels, generalized bone disease, decreased serum phosphorous, and increased renal secretion of calcium and phosphorous. Whereas it was formerly known as a disease of “bones, stones, abdominal groans, and psychic moans,” hyperparathyroidism is now often an asymptomatic disorder diagnosed by routine biochemical screening.

Diagnosis is made by the presence of hypercalcemia and elevated PTH. Additional abnormal laboratory fi ndings may include hypophosphatemia, elevated alkaline phosphatase, and hypercalcuria.

For asymptomatic patients, the NIH consensus statement in 1990 recommended surgery for those with markedly elevated serum calcium levels, substantially reduced bone mass, reduced creatinine clearance, or markedly elevated 24-hour urinary calcium excretion. Surgery is also recommended for asymptomatic patients requesting surgery, patients unlikely to maintain consistent follow-up, and patients less than 50 years old.

Primary hyperparathyroidism (pHPT) is caused by a single adenoma in 80-90% of patients. In 10-20% of cases, and neck surgeons. Being a part of parathyroid hyperplasia or multiple adenomas can be found. Parathyroid carcinoma is a very rare cause of pHPT.

Although it has been stated by some that “the only localization study needed for hyperparathyroidism is to locate a skilled surgeon,” many head and neck surgeons fi nd that preoperative localization studies can substantially reduce operative time and reduce patient morbidity. Accurate localization can confi ne exploration to the identifi ed site, allowing rapid removal of the adenoma. Preoperative imaging modalities include high-resolution ultrasound, CT scan, MRI, and Technetium Tc-99m – labeled sestamibi scan (shown to the right).

In addition, intraoperative rapid PTH testing, and even intraoperative radioactive probe guidance are now allowing for shorter, less invasive surgeries. Intraoperative rapid PTH assays are highly predictive of successful removal of the pathologic glands. Most patients operated on by experienced head and neck surgeons for hyperparathyroidism have a 95% or better cure rate. In some cases, parathyroidectomy may be completed in less than one hour. Hospitalization is generally about twenty-four hours and complication rates are extremely low.