A 75-year-old woman underwent neck exploration for hyperthyroidism 5 years ago, and a parathyroid adenoma was excised. At the present time, she is recover-ing from a myocardial infarction 6 weeks ago, and she is in mild congestive heart failure. Her electro cardio¬ gram shows a slow atrial fibrillation. Measurement of her serine calcium shows a level of 13.0 mg/dL and urine calcium is 300 mg124 h. Studies suggest a small mass in the paratracheal position behind the right clavicle. Appropriate management at this time is (AIPG 2010)
|A||observation and repeat serum calcium in two months|
|B||repeat neck exploration|
|C||superior mediastinal exploration|
|D||ultrasound-guided alcohol injection of the mass|
a. Remedial parathyroidectomy is indicated for persistent and recurrent HPT.
b. Persistent HPT is defined by an inability to achieve normalization of the serum calcium level after initial exploration and represents an immediate technical failure.
c. Recurrent disease is defined by initial normalization of the serum calcium level but then delayed hypercalcemia after 6 months of eucalcemia.
d. Preoperative localization and use of the rapid intraoperative PTH assay are important adjuncts for enhancing success rates during remedial parathyroid surgery.
f. The lateral approach to parathyroidectomy described first by Feind—specifically, dissection between the anterior border of the sternocleidomastoid muscle and the posterior border of the strap muscles—can be invaluable.
g. This approach provides a dissection plane more likely to be free of scar tissue from the previous exploration than the traditional anterior approach does.
h. However this patient is having a myocardial infarction in less than 6 weeks duration and hence wil not be suitable for any form of surgical treatment.
i. Hence the best treatment for this patient is image guided injection of alcohol which acts as a sclerosant and decreases the release of hormones from the mass.