Adenomas of cervical maldescended parathyroid glands: pearls and pitfalls

Ectopic parathyroid adenoma causing hyperparathyroidism-induced psychosis: A case report

Primary hyperparathyroidism is a disease with multisystemic and heterogeneous manifestations, characterized by underlying high parathormone concentrations. Despite neuropsychiatric involvement being one of the manifestations, psychosis is rare. This is the case of a 68-year-old female with a 10-day clinical course of anorexia, mutism, dysphagia, constipation, and weight loss. The patient had disorganized speech associated with paranoid delusions. Prior to this visit, the patient was recently diagnosed with a mixed anxiety-depressive disorder. For this reason, treatment with antidepressants in combination with atypical antipsychotics was administered without a satisfactory response. Neuroimaging, infectious panel, and toxicology screening showed no abnormal findings. Hypercalcemia secondary to a retropharyngeal ectopic parathyroid adenoma was the causative etiology of her primary hyperparathyroidism, and hypercalcemia treatment resolved the psychotic episode. We highlight the importance of recognizing psychosis as a possible initial presentation of hyperparathyroidism and hypercalcemia. Ruling out organic etiologies prior to diagnosing a primary cause of psychosis is crucial, as their treatment can reverse the psychotic symptoms.

Detection of an undescended parathyroid adenoma with 18F-fluorocholine PET/CT

Surgical excision of a parathyroid adenoma (PTA) is the only curative treatment for primary hyperparathyroidism (PHP). The transition from routine bilateral neck exploration to minimally invasive parathyroidectomy has been made possible by preoperative location techniques, including molecular imaging. Here, we present a case of a 76-year-old man with PHP who underwent a [¹⁸F]fluorocholine PET/CT scan, which showed a rare undescended PTA at the level of the right carotid bifurcation. After a successful minimally invasive parathyroidectomy, a PTA was confirmed, and the parathyroid hormone level normalized within 24 h. We conclude that it is relevant to locate preoperatively a PTA accurately to assist the surgeon to perform a successful minimally invasive parathyroidectomy.

Undescended retropharyngeal parathyroid adenoma with adjacent thymic tissue in a 13-year-old boy with primary hyperparathyroidism

We describe a rare presentation of a symptomatic parathyroid adenoma located in an ectopic retropharyngeal position in a 13-year-old boy. Preoperative CT scan and MRI demonstrated the ectopic location of the parathyroid adenoma. The patient underwent successful parathyroidectomy with cure of his hyperparathyroidism. On pathologic exam, the specimen was made up of a parathyroid adenoma and adjacent thymic tissue, indicating that it was likely an undescended lower parathyroid gland arising from the third pharyngeal pouch. Ectopic retropharyngeal parathyroid adenomas are very rare and to our knowledge, none have been previously described in adolescents.

Transoral robotic resection of a retropharyngeal parathyroid adenoma: a case report

Transoral robotic surgery (TORS) has become an increasingly popular option for early malignancies of the oropharynx. It offers superior visualization and has been proven to have acceptable functional and oncologic outcomes. Additionally, indications in head neck have expanded to manage tumors of the thyroid, neck, parapharyngeal space and salivary glands. A 58-year-old female had an incidental finding on CT imaging of a retropharyngeal mass at the level of the hyoid bone. She was referred to a tertiary medical center for further workup and removal of this mass. Due to the midline position of the mass, favorable access and potentially decreased surgical morbidity, TORS excision of the mass was performed for diagnosis and treatment. Histopathology confirmed this to be a hypercellular parathyroid mass consistent with parathyroid adenoma. We report a relatively unusual location of parathyroid adenoma in an asymptomatic patient with normal parathyroid and calcium levels. TORS proves to be a feasible and safe method for complete surgical excision of retropharyngeal parathyroid adenoma without tumor spillage or violation.

Initial surgical results of 500 Parathyroidectomies for Hyperparathyroidism related to chronic kidney disease - mineral and bone disorder

Introduction:

Surgical treatment of hyperparathyroidism related to chronic kidney disease is a challenging procedure even for experienced parathyroid surgeons. Over the years, adjuvant techniques have been developed to assist the medical team to improve surgical outcomes. However, medical staff in poor countries have less access to these techniques and the effectiveness of surgery in this context is unclear.

Objective:

verify the effectiveness of surgery for treatment of hyperparathyroidism related to chronic kidney disease without adjuvant techniques.

Methods:

Over a 5-years period, patients with hyperparathyroidism that had clinical therapeutic failure were evaluated for surgical treatment. Total parathyroidectomy with autograft or subtotal resection were the selected procedures. Surgeries were performed in a tertiary hospital in Brazil without the assistance of some of the adjuvant techniques that are usually applied, such as frozen section, nerve monitoring, and gamma probe. Intraoperative PTH and localization pre-operative exams were applied, but with huge restrictions.

Results:

A total of 518 patients with hyperparathyroidism (128 secondary and 390 tertiary) were surgically treated. Total parathyroidectomy were performed in 81.5%, subtotal in 12.4%, and 61% of patients had a surgical failure. Of all failures, only 1.4% needed a second surgery totaling 98.6% of successful initial surgical treatment. Neck hematoma and unilateral focal fold paralysis occurred in 1.9% and 1.5%, respectively.

Conclusion:

parathyroidectomy is a safe and reproducible surgical procedure even in the absence of adjuvant techniques.

Undescended parathyroid adenomas as cause of persistent hyperparathyroidism

BACKGROUND

Undescended glands are a rare cause of primary and secondary hyperparathyroidism (HPT), but they are more common, however, among patients with recurrent HPT or those who have undergone a failed initial cervical exploration. The currently development of more precise noninvasive imaging techniques has improved the results of preoperative diagnosis of these ectopic lesions.

METHODS

The operative reports of patients undergoing parathyroidectomy at our institution were reviewed to identify patients with an undescended parathyroid gland adenomas. Demographic, clinical, imaging and surgical variables were recorded.

RESULTS

Three patients were included: 2/598 parathyroidectomies performed for primary HPT and 1/93 performed for secondary HPT. One case is presented as jaw tumor syndrome (JTS). All the patients had undergone at least one operation before the definitive focused surgery and represented 6% of our parathyroid reoperations. No significant complications and no recurrences were observed in the long-term follow up.

CONCLUSIONS

Accurate preoperative localization of these lesions was possible with noninvasive studies. High cure rate is possible through selective approach when accurate preoperative localization. Thorough knowledge of parathyroid embryology and meticulous surgical technique are essential, particularly in patients with previous unsuccessful explorations.

Undescended parathyroid adenoma

Undescended parathyroid adenomas are rare, representing 0.08% of all parathyroid adenomas; however, they make up 7% of the underlying cause of failed cervical exploration in patients with persistent primary hyperparathyroidism. A 43-year-old woman with no significant medical or family history presented with fatigue and was diagnosed with primary hyperparathyroidism; however, preoperative imaging including sestamibi scan and ultrasound was unable to identify the hyperfunctioning gland. She underwent a neck exploration and hemithyroidectomy and partial parathyroidectomy with failure of resolution of her disease. Subsequent work up including a CT of the neck demonstrated a 1.9 cm mass adjacent to the left submandibular gland. This was removed with postoperative normalisation of the patient's serum calcium and parathyroid hormone levels.