In this episode of BackTable, Dr. Ashley Agan and guest co-host Dipan Desai (Johns Hopkins) interview David Goldenberg (Penn State) about evaluation and surgical management of parathyroid disease.

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SHOW NOTES

First, the doctors discuss the typical primary parathyroid disease presentation. Patients often report non-specific symptoms, such as fatigue, abdominal pain, sleep issues. Primary hyperparathyroidism is most common in perimenopausal women and is easily misdiagnosed. However, Dr. Goldenberg notes that an elevated serum calcium and PTH level on labs without other causes are diagnostic of primary hyperthyroidism. It is important to rule out other reasons for an elevated calcium level, such as malignancy, thiazides, and lithium. For borderline patients with slightly high parathyroid and calcium levels, the diagnosis is a clinical decision. Dr. Goldenberg may order more imaging studies or check labs again in 6 months. Furthermore, secondary parathyroidism is related to kidney disease and should be treated medically first.

Dr. Goldenberg utilizes a 4D CT scan to localize the overactive parathyroid gland. He notes that a majority of patients will have a single adenoma. Some may have multiple parathyroid glands affected (e.g. 4 gland hyperplasia), and 1% of his patients will have an aggressive parathyroid carcinoma. Parathyroid carcinoma patients usually present with incredibly high calcium and PTH levels. He notes that 4D CT is the most accurate imaging modality for parathyroid visualization; ultrasound is affected by air and bone and a SPECT scan will not detect small or flat adenomas.

Next, Dr. Goldenberg discusses his surgical technique. He makes a clavicle incision at midline and uses the middle thyroid vein to find parathyroid glands. If he is manipulating the superior thyroid glands, he is careful not to damage the recurrent laryngeal nerve. For a 4 gland exploratory surgery, he finds all 4 glands before taking any of them out in order to make sure he is taking out the right one. He can usually distinguish the parathyroid glands from the surrounding tissues because of their unique brown color. If he is unsure about whether the sample he took out is a parathyroid gland or another type of tissue, he will send frozen sections for pathologic analysis. Other pearls he has are: picking up the parathyroid glands from their capsule to preserve blood supply, always using nerve monitoring, and common anatomical locations for missing parathyroid glands. He checks the PTH level before operating and again 15 minutes after parathyroid gland removal to see if he removed the offending gland. If there is at least 50% drop from the baseline PTH level, he considers the surgery a success.

Then, Dr. Goldenberg summarizes his post-operative care. For patients who underwent exploration surgery, he usually keeps them in hospital for 23 hours. Simple parathyroidectomy patients can be discharged on the same day. Patients also receive a calcium taper with calcium carbonate because of the risk of hungry bone syndrome, a condition where serum calcium is depleted quickly because of rapid bone absorption, leading to hypocalcemic symptoms. Hyperparathyroid symptoms usually abate very quickly after surgery. Finally, he discusses his new textbook and atlas, which contains key points and pearls, quiz questions, annotated bibliographies, and surgical videos about head and neck endocrine surgery.

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RESOURCES

Head & Neck Endocrine Surgery: A Comprehensive Textbook, Surgical, and Video Atlas by Dr. David Goldenberg:
https://shop.thieme.com/Head-Neck-Endocrine-Surgery/9781684201464