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434
Manipal Manual of Surgery
ECTOPIC THYROID
• It occurs due to failure of median thyroid anlage to
descend normally. Hence, thyroid tissue can be
found anywhere from the tongue to mediastinum
(Key Box 37.35 and Figs 37.59 and 37.60).
• Ectopic thyroid tissue can have the diseases similar
to normal thyroid tissue, such as solitary nodule,
multinodular goitre, malignancies, etc.
Key Box 37.35
Ectopic Thyroid Tissue
Lingual thyroid
Thyroglossal ectopic thyroid in the upper part of the
neck
Adjacent to aortic arch, aortopulmonary window,
within upper pericardium, etc.
Struma ovarii—malignant ovarian teratoma containing
thyroid tissue.
• Diagnosis is by ultrasound, CT scan. FNAC to
confirm the diagnosis.
• Treatment depends upon the pathology.
INTERESTING ‘MOST COMMON’ FOR THYROID GLAND
• Most common surgical disease of the thyroid gland is
solitary thyroid nodule.
• Most common site of thyroid nodule is at the junction
of isthmus and lobe.
• Most commonly used drug for thyrotoxicosis is
carbimazole.
• Most commonly used investigation for thyroid diseases
is ultrasonogram.
• Most commonly done surgery for well-differentiated
carcinoma thyroid is total thyroidectomy.
• Most common thyroid cancer in children is papillary
carcinoma thyroid.
• Most common thyroid cancer following exposure to
ionising radiation is papillary carcinoma thyroid.
• Most common solitary nodule of thyroid gland is
multinodular goitre.
Fig. 37.60: Ectopic thyroid
tissue in the submandibular region turned out to
be papillary carcinoma
thyroidFig. 37.59: Ectopic thyroid sites
MOST DIAGNOSTIC FEATURES IN THYROID GLAND
• Most diagnostic feature of medullary carcinoma
thyroid is amyloid stroma.
• Most diagnostic feature of papillary carcinoma thyroid
is presence of psammoma bodies.
• Most diagnostic feature of Hashimoto’s thyroiditis is
Askanazy cell.
• Most diagnostic investigation for lingual thyroid is
99m
Tc (technetium) scan.
• Most diagnostic feature of anaplastic carcinoma is
early fixity
• Most diagnostic feature of Graves’ disease is exophthalmos
Section II • General Surgery
Thyroid Gland
435
1. Superior thyroid artery is a branch of:
A. Common carotid artery
B
. Internal carotid artery
C. External carotid artery
D. Thyrocervical trunk
2. Following are true for T3 hormone except:
A. It is more important physiologic hormone
B
. It can be produced by peripheral conversion of
T4
C. It is more quickly acting
D. It is given once a day for suppressive dose
3. Following are true for primary thyrotoxicosis except:
A. 8 times more common in women than men
B
. Gland is vascular and smooth
C. Cardiac failure is common
D. Proptosis is a feature
4. Replacement dose of thyroxin—T4 is:
A. 0.1 mg B. 0.2 mg
. 0.3 mg D. 0.01 mg
C
5. Papillary carcinoma thyroid spreads to which lymph
nodes?
A. Submental
B. Submandibular lymph nodes
C. Scalene nodes
D. Jugular chain of lymph nodes
6. Following is not the common sign of Graves’ disease:
A. Proptosis
B
. Pretibial myxoedema
C. Proximal myopathy
D. Cardiac failure
7. The widely used first investigation of choice in
solitary nodule thyroid is:
A. X-ray neck B. CT scan
C
. MRI D. Ultrasound
9. Following are true for treatment options for toxic
goitre except:
A. Thyroidectomy
. Antithyroid drugs
B
C. Radioiodine treatment
D. Radiotherapy
10. Which one of the following is the treatment of choice
for toxic goitre in a child?
A. Radioiodine
B
. Thyroidectomy
C. Antithyroid drugs
D. Radiotherapy
11. Which is the most effective drug for thyrotoxic
storm?
A. Steroids B. Noradrenaline
C
. IV propranolol D. Carbimazole
12. Which one of these operative steps is not done
routinely in thyroidectomy?
A. Ligation of middle thyroid vein
. Ligation of superior thyroid artery
B
C. Ligation of inferior thyroid artery
D. Ligation of inferior thyroid veins
13. A few landmarks for identification of recurrent
laryngeal nerve include following except:
A. Parallel to tracheo-oesophageal groove on the left
side
. Below the inferior thyroid artery on the right side
B
C. Between branches of the inferior thyroid artery
D. Between the branches of inferior thyroid veins
14. Following are true for external branch of superior
laryngeal nerve except:
A. It is close to superior thyroid artery
. Paralysis of this nerve leads to loss of tension in
B
the vocal cord
C. Paralysis of this nerve diminishes power and range
in the voice
D. It supplies adductors of the vocal cord
8. Which one of the following is not the treatment for
Graves’ disease?
A. Carbimazole
B
. Propranolol
C. Massive doses of steroids in ophthalmopathy
D. Digoxin
15. Following are true for papillary carcinoma thyroid
except:
A. Childhood irradiation is an important cause
. Orphan Annie-eyed nuclei is characteristic
B
C. Multiple foci are common in the same lobe
D. It spreads predominantly by blood spread
Section II • General Surgery
436
Manipal Manual of Surgery
16. Single most important aetiological factor in papillary
carcinoma is:
A. Endemic goitre
. Childhood irradiation
B
C. Autoimmune thyroiditis
D. Multiple endocrine neoplasia syndromes
17. Following are the important steps of surgery for well-
differentiated thyroid cancers of more than
2 cm in size except:
A. Lobectomy
B
. Total thyroidectomy
C. Selective neck dissection
D. Removal of all macroscopic diseases
18. Following are true after total thyroidectomy before
radioiodine scan except:
A. If T
is given, only one week of stopping of
3
hormone is enough
B. Otherwise minimum 4 weeks stoppage of T4 is
required
C. Alternative to thyroxine withdrawal is to
administer synthetic TSH over 48 hours
D. TSH administration is not at all effective
19. Following are true about thyroglobulin except:
A. Normal levels are not detectable
B
. Increasing levels indicate metastasis in papillary
carcinoma thyroid
C. Increasing thyroglobulin prompts surgeon to get
ultrasound of the neck
D. Useful in medullary carcinoma thyroid
20. Following are true for medullary carcinoma thyroid
except:
A. Calcitonin is the tumour marker
. It arises from parafollicular cells
B
C. It has amyloid stroma
D. It can be treated by lobectomy
21. Following is an indication for core needle biopsy of
thyroid swellings:
A. Lymphoma
. Papillary carcinoma thyroid
B
C. Follicular carcinoma thyroid
D. Medullary carcinoma thyroid
22. Following are pathological features of papillary
carcinoma except:
A. Microcarcinoma
B
. Orphan Annie-eyed nuclei
C. Tall cell cancer
D. Hürthle cell cancer
23. Following are true for medullary carcinoma thyroid
except:
A. It arises from parafollicular cells
. Cells are like carcinoid tumour
B
C. Does not spread by lymphatics
D. Tumours are not TSH dependent
24. Follicular carcinoma thyroid is diagnosed by:
A. Orphan Annie-eyed nuclei
B
. Askanazy cell
C. Angioinvasion and capsular invasion
D. Amyloid stroma
25. Non-operative treatment can be offered in a solitary
nodule except:
A. Cyst less than 1 cm size
B
. Colloid goitre less than 1 cm in size
C. Retrosternal goitre
D. Hashimoto’s thyroiditis
26. Parafollicular cells are located in which part of
thyroid gland?
A. Upper pole
. Lower pole
B
C. Isthmus
D. Organ of Zuckerkandl
27. About recurrent laryngeal nerve (RLN) following are
true except:
A. RLN crosses medial to inferior thyroid artery
B
. Superior parathyroid is posterior to RLN
C. Inferior parathyroid is 1 cm away from RLN
D. RLN passes immediately medial to tubercle of
Zuckerkandl.
Answers
1. C 2. D 3. C 4. A 5. D 6. D 7. D 8. D 9. D 10. C
11. C 12. C 13. D 14. D 15. D 16. B 17. A 18. D 19. D 20. D
Section II • General Surgery
21. A 22. D 23. C 24. C 25. C 26. A 27. C
38
Parathyroid and Adrenals
Surgical anatomy
Congenital anomaly
Physiology—calcium and action of PTH and
calcitonin
Tetany
Hyperparathyroidism
Cryopreservation
SU22.5: Describe the applied anatomy of parathyroid.
PARATHYROID GLANDS
SURGICAL ANATOMY
• These are the endocrinal glands situated in the neck
and secrete the hormone parathormone (PTH). Their
secretion is not dependent on pituitary gland.
• They are 4 in number; 2 on the right and 2 on the left.
• Superior parathyroids are derived from endoderm
of 4th branchial arch and thus, they develop along
with the thyroid gland. Superior parathyroids are
found in relation to inferior thyroid artery in the
middle of posterior aspect of thyroid gland. They are
situated in the fat above inferior thyroid artery, close
to cricothyroid artery and cricothyroid articulation.
They are constant in position. They are smaller
(30–40
mg). They are dorsal to recurrent laryngeal
nerve (RLN).
• Inferior parathyroids develop from endoderm of 3rd
branchial arch (with thymus) and are not constant in
position.
They may be seen in the lower pole, within
fascial sheath of thyroid gland, low down in the
neck (rarely in the mediastinum), outside the fascial
sheath or even within thyroid gland. They are large
(30 to 50 mg). They are ventral to RLN (Fig. 38.1).
Acute hypercalcaemic crisis
Adrenal glands—anatomy, physiology
Disorders of adrenal cortex
Neuroblastoma
Phaeochromocytoma
Incidentalomas
Fig. 38.1: Location of inferior parathyroid gland
• Parathyroids appear golden-yellow to light brown
in adults. In children, they are pinkish in colour.
Blood Supply
Inferior thyroid artery supplies both the parathyroids
in about 95% of cases by a leash of vessels. Ligature of
both inferior thyroid arteries may not result in hypo-
parathyroidism because there is adequate collateral
circulation and a few branches of superior thyroid artery
also supply 20% of upper glands.
Histology
Principal cells (chief cells) are the cells which secrete PTH
(parathormone). Water clear cells (rich in glycogen) are
found in hyperplastic and neoplastic glands.
437
438
Manipal Manual of Surgery
CONGENITAL ANOMALY AND SYNDROME
DiGeorge syndrome: Congenital absence of the parathyroid glands and thymus. Neonatal hypoparathyroidism along with absence of thymus-dependent
lymphoid system.
PHYSIOLOGY—CALCIUM AND ACTION OF
PTH AND
CALCITONIN
PTH is a peptide containing 84 amino acids. It is secreted
in response to increase in calcium or decrease in
magnesium. Actions of PTH are:
. Resorption and mobilisation of calcium from the bone
1
(Key Box 38.1).
2. Increased reabsorption of calcium from kidney
prompting excretion of phosphate.
3. Enhances absorption of calcium from the gut.
• Thus, PTH increases serum calcium level.
• Normal serum calcium level 9–11 mg/dl (total).
• In normal persons, the PTH is balanced by
calcitonin, secreted from C cells of the thyroid
glands.
TETANY
Tetany is a condition wherein there is hyperexcitability
of peripheral nerves.
Causes of Tetany
1. Hypoparathyroidism: It results from surgical
removal of parathyroids. Subtotal thyroidectomy and
near-total thyroidectomy are the most common
causes of tetany. Hypoparathyroidism may be
‘familial’ variety or neonatal variety. It may be
temporary after thyroidectomy or permanent, if all
the 4 parathyroids are removed or deprived of their
blood supply. The incidence is around 1–2%.
2. Severe respiratory alkalosis can cause tetany as in
hyperventilation.
. Low calcium levels can occur due to dietary factors
3
or poor absorption from the gut or acute pancreatitis,
chronic renal failure, etc.
4. Osteomalacia and rickets due to deficiency of
vitamin D.
5. Hypokalaemic alkalosis of pyloric stenosis.
6. Following massive transfusion (citrate overload).
Key Box 38.1
Calcium
Most abundant cation in human beings
50% of calcium is in the ionised form, which can be
measured
50% of calcium is bound to albumin. Hence, total
calcium levels will be low when albumin levels are low
Total calcium levels: 9–11 mg/dl
Calcium is absorbed in the small intestines
Sources of calcium: Milk, yoghurt and cheese, green
peas, beans, oranges. Daily requirement: 1000–1300 mg/
day
Calcium is an important ion for blood coagulation,
cellular activity, bone density and neuromuscular activity
CALCITONIN
• It is released from ‘C’ cells—parafollicular cells of the
thyroid gland.
• Normal values are unmeasurable less than 10 pg/ml.
• It reduces calcium levels by inhibiting activity of
osteoclasts. Thus its action is opposite that of PTH.
• It also increases excretion of calcium in the urine.
SU22.6: Describe and discuss the clinical features of
hypo- and hyperparathyroidism and the principles of their
management.
Section II • General Surgery
Signs and Symptoms (Key Box 38.2)
Key Box 38.2
Tetany—Clinical Features
Creaking or grating sound (stridor)
Circumoral pallor
Carpopedal spasm—Trousseau’s sign
Chovstek’s sign
Clonic seizure
Convulsions (rare)
Observe 6 ‘Cs’
1. Tingling and numbness
of the fingers, toes, lips
(circumoral paraesthesia)
and occasionally, with
circumoral pallor.
2. Cramps of the hands and
feet.
3. In severe hypocalcaemia,
there may be carpopedal
spasm. Metacarpophalan-
geal (MP) joints are flexed,
interphalangeal joints are
extended and the thumb
is adducted. This is called
thumb in palm deformity
(obstetrician’s hand). In
the foot, extension in the
Fig. 38.2: Severe tetany
following removal of the parathyroid adenoma requiring
calcium infusion
ankle joints and flexion of the toes are seen (Fig. 38.2).
Parathyroid and Adrenals
439
4. Stridor is a dangerous complication of severe tetany
due to spasm of muscles of respiration.
5. Latent tetany can be diagnosed by:
• Tapping the facial nerve at the angle of jaw. This
produces twitching of eyelids, corner of the mouth,
etc. It is called Chvostek’s sign. It indicates facial
nerve hyperexcitability.
• Trousseau’s sign: When a blood pressure cuff
applied to the arm is inflated above the systolic
pressure (200 mm of Hg), the hands and feet go
into spasm (obstetrician’s hand, carpopedal
spasm).
. Spasm of intraocular muscles results in blurring of
6
vision.
7. Convulsions, even though rare, can occur in infants.
Diagnosis
This is established by estimating serum calcium level
which is usually <7 mg%.
Treatment
1. Oral calcium such as calcium lactate, calcium
gluconate may relieve mild symptoms.
. In acute cases, injection calcium gluconate 10%
2
(10 ml) should be given slowly intravenously over
10 minutes to avoid cardiac arrhythmias.
3. If any precipitating cause is detected, it needs to be
corrected.
HYPERPARATHYROIDISM (HPT)
Hyperparathyroidism is an uncommon disease and
occurs due to an increased activity of parathyroids and
manifests as hypercalcaemia.
PRIMARY HYPERPARATHYROIDISM
Incidence
0.50 to 1 per 1000 population in United States. More
common in postmenopausal women.
Aetiology
• Exact cause of primary hyperparathyroidism (PHPT)
is unknown.
1. Familial/genetic: Can be a part of MEN syndrome
and MENII A or familial PHPT with jaw tumour
syndrome. Both occur due to genetic mutation.
Primary HPT is the earliest and most common manifestation
of MEN type I and develops in 80–100% of these patients by
40 years of age.
2. Low dose therapeutic ionising radiation is also one
of the causes.
3. Lithium is associated with parathyroid hyperplasia and primary HPT. Interestingly there is no
hypercalciuria and bone mineral density is not
affected.
4. Renal leak of calcium and declining renal function
with age may also be causative factors for primary
HPT.
Pathology (Key Box 38.3)
• Single chief cell adenoma is the most common cause
(80%). It can be due to diffuse hyperplasia involving
all 4 glands (5–10% of cases).
• Very rarely, it can be due to carcinoma arising in the
parathyroid glands (1%).
• Adenoma can be a part of multiple endocrine neo-
plasia (MEN) syndrome.
I
Types of Hyperparathyroidism
• Primary hyperparathyroidism: It refers to hyper-
activity of parathyroids due to an adenoma or
primary hyperplasia of parathyroid glands.
• Secondary hyperparathyroidism: It occurs due to
persistently low levels of calcium as in chronic renal
failure and malabsorption, which results in decreased
levels of calcium and increased levels of hyperphosphataemia.
• Tertiary hyperparathyroidism: This is seen in
patients who undergo dialysis and transplantation
for chronic renal failure. After a few years of prolonged stimulation, autonomy develops and the
secondary hyperparathyroidism changes into tertiary
hyperparathyroidism. They can also have problems
similar to primary hyperparathyroidism.
Clinical Features
• Common in females: Female to male ratio is 4:1.
• Age: 30–60 years, the most common age group is
5th decade—middle aged
• Incidence is 1:1000 patients.
Key Box 38.3
Pathology
Adenoma—reddish brown, only 1 gland is enlarged
Chief cell hyperplasia—reddish brown, >1 gland is
enlarged
Water cell hyperplasia—chocolate brown, >1 gland is
enlarged
Multiple gland enlargement is a feature of familial
disease
Section II • General Surgery
440
Manipal Manual of Surgery
• The most common presentation is asymptomatic
hypercalcaemia in about 50% of the patients and
renal stones in 25% of the patients. The clinical
features are as follows.
1. Bone Disease—Painful Bones
Due to increasing levels of PTH, extensive skeletal
decalcification occurs. This results in bony pains,
pathological fractures due to brittle bones, subperiosteal
erosions, cysts in the phalanges, mandible, skull, etc.
They are called pseudotumours. The changes are
similar to that seen in osteitis fibrosa cystica (von
Recklinghausen’s disease). Thus, osteopenia, osteoporosis and osteitis fibrosa cystica are found in 15% of
PHPT.
2. Renal Disease—Renal Stones
• Increased calcium levels result from increased
calcium absorption from the kidneys. Hence, patients
are prone to develop renal stone and nephro-
calcinosis (calcification of kidney), hypertension.
• Calcium also increases the tone of the vessels which
adds to the hypertension. Primary hyperparathyroidism is the cause of stones in 1
–3% of all
patients with kidney stones and in 10% of those who
have recurrence of stones.
• Calculi are specially composed of calcium phosphate
or oxalate.
3. Abdominal Groans
• Calcium stimulates gastrin which is a powerful
stimulator of acid. This may result in pain abdomen
due to peptic ulcer. The patient can present with
dyspeptic symptoms.
• Calcium can cause pancreatitis, resulting in pain
radiating to the back.
• Metastatic calcification is also a feature.
• Increased incidence of gallstones has been reported
as a consequence of increase in secretion of calcium
in the bile-calcium bilirubinate stone.
• All these factors result in abdominal pain, which has
been called abdominal groans.
4. Psychiatric Moans
• Hypercalcaemia can result in depression, fatigue,
anxiety, psychosis and even coma.
• These patients, more often women, mostly middle
age, having bony pains, backaches and behavioural
abnormalities are thought to have a psychiatric
illness. They are referred to mental institutions,
orthopaedic department, gynaecology department
Section II • General Surgery
and are shunted from doctor to doctor.
5. Fatigue Overtones
Many patients present with weakness and fatigue.
PHPT is a disease of stones, painful bones, abdominal groans,
psychiatric moans and fatigue overtones.
Acute Presentation of Hypercalcaemia
• Abdominal pain
• Oliguria
• Dehydration
• Vomiting
• Coma
Symptoms
• Asymptomatic 50–60% of cases
• Renal stones 25–30%
• Bone disease 8–10%
• Joint pains 3–5%
• Abdominal pain (peptic ulcer) 3–5%
• Hypertension 3–5%
Other Features (Key Box 38.4)
• Corneal calcification/band keratopathy (inside
iris) may be seen in the eye on slit-lamp examina-
tion.
• Proximal myopathy, muscle wasting is also seen.
• Interestingly, clinical examination of the neck may not
reveal any parathyroid enlargement. Hence, the
diagnosis should be suspected by the various
symptoms. High index of suspicion is necessary in
arriving at a proper diagnosis.
Key Box 38.4
Primary Hyperparathyroidism and Calcinosis
Nephrocalcinosis and renal stones
Cholelithiasis
Chondrocalcinosis
Calcification at ectopic sites such as blood vessels,
cardiac valves, skin, etc.—metastatic calcification
Note: Soft tissue calcification and tumoural calcinosis occur in
secondary hyperparathyroidism.
When a patient develops multiple urinary calculi, reduced
bone density, high serum calcium, symptomatic hypercalciuria
and pathological fractures, suspect primary HPT and request
for PTH assay.
Parathyroid and Adrenals
441
Investigations
Investigations can be classified as follows:
I. To prove hyperparathyroidism
• Serum calcium, phosphate, albumin
• Serum PTH assay
• Alkaline phosphatase
• X-ray of bones.
II. To localise parathyroid glands
• Ultrasound of neck
• Thallium and technetium subtraction scan
• Selective venous sampling with PTH assay. This
is most reliable but more difficult.
• Sestamibi scanning.
I. To Prove Hyperparathyroidism
1. Serum calcium levels are always raised above normal
limits (9–11 mg%). There are many causes of hypercalcaemia which are depicted in Key Box 38.5. Hence,
estimation of serum calcium alone will not give the
diagnosis.
2. Albumin is the main calcium binding protein in the
plasma. Hence, it should also be measured.
. Serum PTH level which is estimated by immunoassay
3
is the diagnostic investigation. It is called tumour
marker for hyperparathyroidism. Estimation of PTH
is difficult, costly and needs sophisticated set up.
4. Serum phosphorus levels are decreased.
5. Alkaline phosphatase is increased when bones are
involved.
Key Box 38.5
Causes of Hypercalcaemia
Endocrinal Primary hyperparathyroidism
Thyrotoxicosis
Phaeochromocytoma
Malignancy Multiple bone secondaries
1
—(Ca
breast, prostate, kidney, follicular
carcinoma thyroid)
Multiple myeloma, oat cell carci-
2
noma
Renal failure Secondary and tertiary hyperpara-
thyroidism
Nutritional Vitamin D intoxication
Chronic disease Tuberculosis sarcoidosis
Skeletal Paraplegia, quadriplegia patients
also are immobilised—hypercalciuric hypercalcaemia
1
The common causes are carcinoma breast, prostate, kidney,
bronchus, follicular carcinoma of the thyroid.
2
It produces PTH-like polypeptide (pseudohyperparathyroidism).
6. X-ray of the hand may reveal decalcification cysts
in the phalanges, telescoping of fingertips, etc. X-ray
of the skull may reveal subperiosteal erosions,
hazy outline of the skull and pepper pot appearance
(Key Box 38.6) (Figs 38.3 to 38.5).
Key Box 38.6
Interesting Radiological Changes
Osteopenia Bone density loss in cortical
bone—radius
Bone cysts and Aggregation of osteoclasts
brown tumours (osteoclastoma)
Rugger Jersey spine Generalised loss of bone
density
Pepper pot skull Demineralised bone—
mottled appearance
Subperiosteal Seen in radial aspect of
resorption middle phalanges of 2nd
(pathognomonic) and 3rd fingers, bone cysts
and tufting of the distal
phalanges
II. To Localise Parathyroid Glands
. High frequency ultrasound of the neck can be very
1
accurate in the hands of an experienced sonologist.
It can also detect renal disease, pancreatic disease,
etc. It cannot scan behind sternum and cannot pick
up lesions less than 0.5 cm. Specially useful in
detecting intrathyroidal parathyroid adenoma
(sensitivity is about 75%) (Figs 38.6 and 38.7).
2. Thallium-technetium isotope scan: First the thyroid
is outlined with
99m
Tc and then isotope
201
TICl
(thallium chloride) is administered. This is taken up
by both the thyroid and parathyroid. By computer
subtraction of the two and enlargement of images,
the parathyroid appears as a hot spot.
99m
3. Technetium 99m (
Tc)–labelled sestamibi (MIBI)
scanning: MIBI (methyl-isobutyl-isonitrile radio-
nuclide—sestamibi is concentrated in tissues rich in
mitochondria)
• Heart
• Salivary glands
• Thyroid glands
• Parathyroid glands
This test has proved to be superior to thallium and
technetium subtraction scanning.
• Sestamibi is a protein labelled with technetium 99m
that localises diseased gland—most widely used
and is an accurate modality.
• It is very sensitive to identify adenomas (90%)
than hyperplasia.
Section II • General Surgery
442
Manipal Manual of Surgery
Fig. 38.3: Generalised osteopenia and sub-
peristeal resorption of the radial aspect of middle
phalanx—tunnelling of the cortex (double lines)
is seen
Fig. 38.6: Ultrasonography of the neck reveals heterogeneous
nodule predominantly echogenic
Fig. 38.4: X-ray skull showing multiple lytic
sclerotic lesions—pepper pot appearance
Fig. 38.5: X-ray forearm bones
showing osteopenia
Fig. 38.7: Ultrasonography of the abdomen shows gallstone with
posterior acoustic shadow
(Courtesy: Figs 38.3 to 38.7 Dr Rajgopal KV, Head, Department of Radiology, KMC Manipal)
Fig. 38.8: Sestamibi scan shows bright spot—parathyroid
adenoma
Section II • General Surgery
. He also had hypercalcaemia (Key Box 20.10)
Figs 38.9 and 38.10: Fusion of single-photon emission computed
tomography (SPECT) and computed tomography data, shows
the site of ectopic parathyroid adenoma
Parathyroid and Adrenals
443
• However, it is very expensive. Hence, it can be
used in ‘Re-exploration of neck’ for parathyroidectomy.
4. SPECT: Single Photon Emission Computed
Tomography when used with sestamibi is useful in
evaluation of ectopic parathyroid adenomas—deep
in the neck or mediastinum (Figs 38.8 to 38.10).
CT scan, PET scan and MRI are not indicated prior to first time
surgery.
Indications for Surgery
1. Symptomatic hyperparathyroidism
. Serum calcium greater than 20 mg%
2
3. Renal stones
4. Hypercalciuria (>400 mg/day)
5. Decreased creatinine clearance by 30%
6. Reduced cortical bone density
Treatment
A. Intraoperative recognition of parathyroid
1. Radioguided parathyroidectomy—it is possible if
there is a preoperative MIBI scan.
. Frozen section has failure rates about 2–3%.
2
3. Intraoperative tissue aspirate PHT—in primary HPT.
4. Methylene blue is not recommended because of the
risk of toxic encephalopathy.
B. Surgery: The surgery of the parathyroid glands needs
patience, skill and expertise. The neck is explored
with a collar neck incision (3–4 cm) caudal to cricoid
cartilage. Parathyroid gland, when it is enlarged
can be dark-brown or chocolate brown colour.
Occasionally, the surgeon is lucky to encounter a
single adenoma usually located on the posterior
surface of the thyroid gland, when it arises from
superior parathyroid (Key Box 38.7). Very often,
identification of the parathyroid may be difficult
because they may be intrathyroidal or within the
mediastinum (Key Box 38.8).
Key Box 38.8
When you cannot Identify at Surgery?
Divide thyrothymic ligament.
Search in tracheoesophageal groove.
Call for intraoperative ultrasound to rule out intra-
thyroidal gland.
Incise and look inside carotid sheath.
Remove thymus—send it for frozen section.
Sometimes parathyroid can be more than 4.
Do sternotomy—last step.
• Frozen section of
parathyroid glands is
essential to confirm
whether it is an adenoma or hyperplasia
because treatment
depends upon the
pathology of the
gland (Key Box 38.9).
1. Single adenoma:
Excision of the gland.
However, one other
normal parathyroid
gland is also removed
for histopathological
study (Fig. 38.11).
Single adenoma is more common cause of PHPT in about 80%
of patients. Multiple adenomas are more common in older
patients.
Fig. 38.11: Proved to be
adenoma—rest of the glands
not enlarged (Cour
Ramachandra, Dr S Prasad,
Dr Chethan, Department of
Surgery, KMC, Manipal)
tesy: Prof. L
2. Diffuse hyperplasia: 3½ or 3¾ parathyroids are
removed and small pieces are autotransplanted
into the forearm muscle tissue. In case there is hyper-
activity of this parathyroid tissue, surgical exploration becomes easy. At the same time, if this functions
normally, patient will not develop hypoparathyroidism (13–14 pieces of 1 mm each in brachioradialis)
Key Box 38.7
Identification of Parathyroid at Surgery
Bloodless field is necessary.
Ligate middle thyroid vein. Then, retract thyroid gland
medially and anteriorly.
Identify inferior thyroid artery and recurrent laryngeal
nerve.
Parathyroids are covered by fat.
Incise fat lobule.
Parathyroid ‘pops out’.
Parathyroid autotransplantation
• Indicated after removal of all four parathyroids and in
HPT with renal failure.
• 1 mm × 1 mm × 2 mm pieces are made from para-
thyroid tissue and placed in sterile iced saline.
• It is transplanted in patient’s nondominant forearm
within fibres of brachioradialis.
• 4 to 5 pieces (about 100 mg) are transplanted.
• Sutured with silk.
• It will take 14–21 days for parathyroids to function.
Section II • General Surgery