Thyroid & Adrenal
A 75-year-old woman underwent neck exploration for hyperthyroidism 5 years ago, and a parathyroid adenorqa was excised. At the present time, she is recovering 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
|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.
e. Reoperative neck exploration is more difficult because of scar tissue and distortion of normal tissue planes.
f. It is more dangerous because of a greater chance of injury to the recurrent and superior laryngeal nerves.
g. It is sometimes necessary to perform a partial or (rarely) complete median sternotomy at the time of re-exploration for parathyroids located in the mediastinum.
h. Success rates of 85% to 95% can be achieved by experienced endocrine surgeons in the remedial setting.
i. However this patient is having a myocardial infarction in less than 6 weeks duration and hence will not be suitable for any form of surgical treatment.
j. 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.