Abstract
Hyperparathyroidism is a common disorder affecting more than hundreds of thousands
of people annually. While most commonly secondary to an adenoma, it may also arise
from four-gland hyperplasia or malignancy. In the case of primary hyperparathyroidism,
the number of glands involved may be unknown prior to surgery. In contrast, the metabolic
disorder associated with renal failure induced hyperparathyroidism ensures a hyperplasia
picture. Despite the uniform hyperplasia seen in tertiary disease and the preoperative
expectation for four-gland exploration, our case demonstrates the continued need for
a surgeon's vigilance during dissection to identify all glands and appropriately use
intraoperative parathyroid hormone (PTH) testing. In addition, while intraoperative
PTH assessment is an effective method for confirming adequacy of treatment for hyperparathyroidism,
only surgical pathology can confirm malignancy, which should be considered with PTH
levels > 1,000. The case also underscores the importance of comprehensive surgery
management and mindful interpretation of intraoperative PTH levels in the management
of hyperparathyroidism. Standard surgical technique includes complete exploration
of the central compartment, and thyroid lobectomy when the aforementioned exploration
fails to reveal the necessary parathyroid tissue, especially with a persistently elevated
PTH. Without a standardized progressive compartment exploration and judicious use
of intraoperative hormone testing, intrathyroidal parathyroid glands can be missed.
Keywords
tertiary hyperparathyroidism - parathyroid cancer - intrathryoidal parathyroid - intraoperative
PTH - parathyroidectomy
