BackTable / ENT / Podcast / Episode #85
Surgical Management of Parathyroid Disease
with Dr. David Goldenberg and Dr. Dipan Desai
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.
BackTable, LLC (Producer). (2023, January 17). Ep. 85 – Surgical Management of Parathyroid Disease [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. David Goldenberg
Dr. David Goldenberg is a professor and the chair of the department of otolaryngology - head and neck surgery at Penn State in Hershey, Pennsylvania.
Dr. Dipan Desai
Dr. Dipan Desai is a practicing otolaryngologst and head and neck surgeon with ENT Associates in St. Petersburg, Florida.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
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.
Head & Neck Endocrine Surgery: A Comprehensive Textbook, Surgical, and Video Atlas by Dr. David Goldenberg:
If this is a first-time parathyroid and we know where it is, I approach this much like I do a thyroidectomy. We make a very small incision about the level of a coker incision, so two fingerbreadths above the clavicles in the midline. It's about an inch, a little more than an inch and a half. We move the strap muscles aside, medialize the thyroid gland. If I know where it is and it's lower parathyroid, then sometimes you don't have to take the middle thyroid vein, but oftentimes you do to adequately mobilize the thyroid gland and then we find the parathyroid
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