[Non-functioning parathyroid cysts]. / Nefunktsional'nye kisty okoloshchitovidnykh zhelez.

OBJECTIVE: To study the features of clinical course, diagnosis and treatment of true non-functioning parathyroid cysts. MATERIAL AND METHODS: We retrospectively analyzed 18 patients with non-functioning true parathyroid cysts. Inclusion criteria: US-confirmed anechoic lesion of the neck without tissue component, cytological data on cystic lesion, high cystic parathyroid hormone and no laboratory signs of hyperparathyroidism. RESULTS: Non-functioning parathyroid cysts were asymptomatic and diagnosed accidentally after ultrasound of the neck. All patients were women aged 35-77 years. Four patients had cysts near the upper parathyroid glands, 14 patients - near the lower parathyroid glands. Of these, 2 ones had cysts below the level of the clavicle. Cyst volume was 4.3-110.3 cm3 (24.1±26.2 cm3). High cystic parathyroid hormone (2012.5±946.7 pg/ml) was observed in all patients. Simple aspiration was performed in 5 patients, aspiration with sclerotherapy - in 10 patients, cystectomy - in 3 patients. Recurrence was diagnosed in 1 patient after aspiration and 2 patients after sclerotherapy. CONCLUSION: No pathognomonic clinical and ultrasonic symptoms, as well as specific cytological data lead to misdiagnosis. Analysis of PTH in non-functioning parathyroid cysts is essential for diagnosis. Minimally invasive treatment is preferable for true parathyroid cysts. However, these approaches are not radical.

Overview of Thyroid and Parathyroid Disease-The Endocrinology Perspective.

Thyroid and parathyroid disorders are quite common in the population and range from benign to malignant conditions that may be hormonally active or inactive. Select disorders of the thyroid and parathyroid can be managed medically, although there are a variety of circumstances that may require definitive management with surgery. Surgical intervention may be required for hormonal control, compressive symptoms, or for the removal and/or control of malignancy. The endocrinologist's perspective of the preoperative and postoperative management regarding thyroid and parathyroid surgeries will be discussed.

Overview of Thyroid and Parathyroid Disease: The Otolaryngology Perspective.

The management of thyroid and parathyroid pathology varies widely, with unifying goals of symptomatic control and mitigating patient morbidity. In general, surgery is indicated when addressing malignancy or when medical management is insufficient. Over the last few decades, treatment paradigms for patients with head and neck endocrine disease have shifted significantly as our understanding of disease processes has expanded and with the advent of numerous relevant technologies. Here we provide a general overview of thyroid and parathyroid disease that may be managed by the otolaryngologist, with attention to emerging strategies in diagnosis and treatment.

A contemporary analysis of the pre- and intraoperative recognition of multigland parathyroid disease.

BACKGROUND: Despite advances in biochemical and radiological identification of parathyroid gland enlargement, primary hyperparathyroidism (PHPT) due to sporadic multigland parathyroid disease (MGPD) remains a perioperative diagnostic dilemma. Failure to recognise MGPD pre- or intraoperatively may negatively impact surgical cure rates and result in persistent PHPT and ongoing patient morbidity. METHODS: We have conducted a comprehensive review of published literature in attempt to determine factors that could aid in reliably diagnosing sporadic MGPD pre- or intraoperatively. We discuss preoperative clinical features and examine pre- and intraoperative biochemical and imaging findings concentrating on those areas that give practicing surgeons and the wider multi-disciplinary endocrine team indications that a patient has MGDP. This could alter surgical strategy. CONCLUSION: Biochemistry can provide diagnosis of PHPT but cannot reliably discriminate parathyroid pathology. Histopathology can aid diagnosis between MGPD and adenoma, but histological appearance can overlap. Multiple negative imaging modalities indicate that MGPD may be more likely than a single parathyroid adenoma, but the gold standard for diagnosis is still intraoperative identification during BNE. MGPD remains a difficult disease to both diagnose and treat.

[Ultrasound-guided anhydrous ethanol and microwave ablation for functional parathyroid cyst: a case report].

We report a case of functional parathyroid cyst treated by ultrasound-guided anhydrous ethanol sclerotherapy and microwave ablation. The 63-year-old female patient was diagnosed to have functional parathyroid cyst with hypercalcemia, high PTH and cystic space-occupying lesions in the neck by ultrasound, radionuclide scanning and PTH measurement of the cystic fluid. The patient refused to receive cyst resection, and anhydrous ethanol sclerotherapy with microwave ablation was performed under ultrasound guidance. The procedure was completed smoothly without any complications either during or after the operation. Follow-up examination of the patient at 18 months after the operation showed a significant reduction of the mass and normal blood calcium and iPTH levels, demonstrating a clinical cure of the patient. Ablative treatment of functional parathyroid cyst has not been documented so far. This approach provides a minimally invasive treatment modality for such cases where surgical resection is not an option, but its efficacy and safety need to be evaluated in more cases with longer follow-up time.

[Safe thyroidectomy for thyroid and parathyroid diseases]. / Puti osvoeniya bezopasnoi tekhniki tireoidektomii pri zabolevaniyakh shchitovidnoi i okoloshchitovidnykh zhelez.

OBJECTIVE: To offer the ways for safe thyroidectomy aimed at prevention of damage of recurrent laryngeal nerve in patients with thyroid and parathyroid diseases. MATERIAL AND METHODS: We analyzed postoperative outcomes after thyroidectomy in 342 patients aged 20-80 years. Topography of recurrent laryngeal nerves was studied on 20 laryngeal-tracheal complexes of deceased patients. Technique of visualization of various segments of recurrent laryngeal nerve was worked out. RESULTS AND DISCUSSION: Thyroidectomy was performed in 342 patients with thyroid and parathyroid diseases. Thyroidectomy was performed in accordance with recommendations described by F.W. Lahey, W.B. Hoover (1938) and H. Malcolm, M.D. Wheeler (1998). Location of recurrent laryngeal nerve varied in patients with nodular, retrosternal goiter and parathyroid gland adenoma. Comparison of intraoperative and morphological data on recurrent laryngeal nerve visualization showed possible risks of its damage during manipulations on thyroid gland, esophagus and trachea. Our study confirmed the need for visualization and mobilization of recurrent laryngeal nerve in all procedures on thyroid and parathyroid glands. Introduction of the described technique of thyroidectomy and training sessions for recurrent laryngeal nerve mobilization on laryngeal-tracheal complexes reduced postoperative incidence of phonation disorders from 21.6% to 0.98%. CONCLUSION: Thyroidectomy may be a safe procedure if surgeons are familiar with the details of surgical technique and prevent damage to adjacent structures.

Real-time intraoperative near-infrared autofluorescence imaging to locate the parathyroid glands: A preliminary report.

Identification and localization of parathyroid glands (PGs) remains a challenge for surgeons. The aim of this study was to evaluate the efficiency of intraoperative near-infrared autofluorescence (NIRAF) imaging to detect PGs in thyroid and parathyroid diseases. Seventy-six patients undergoing surgery for thyroid or parathyroid diseases between July 9, 2020 and August 20, 2021 were retrospectively analyzed. Intraoperative carbon nanoparticle (CN) negative imaging and handheld NIRAF imaging were successively performed for each patient. Of 206 PGs that needed to be identified for surgery, 162 were identified by NIRAF imaging, with a theoretical rate of identification of 78.64%. This was higher than the rate of identification with CN negative imaging, which was 75.73%. The number of PGs identified by NIRAF imaging and CN negative imaging did not differ significantly in either total thyroidectomy or thyroid lobectomy. In addition, the autofluorescence (AF) intensity of secondary parathyroid adenoma was weaker than that of normal PGs. NIRAF imaging is potentially a more efficient tool for identification of PGs than CN negative imaging, with a shorter learning curve and lower risk. It may not be well-suited to secondary hyperthyroidism or adenoma, but it was more efficient at identifying excised specimens than visual identification by a surgeon.

Misdiagnosed giant parathyroid cyst: differential diagnosis of a neck mass of the central region.

Parathyroid cysts (PCs) are rare benign lesions representing between the 0.08% and the 0.34% of the neck masses going on surgery. They should be considered in the differential diagnosis of neck masses, especially in the differential diagnosis of the cystic anterior neck masses.Approximately 300 cases of PC are reported within the international literature.The gold standard for diagnosis is the evidence of high-level intact parathyroid hormone in cystic fluid. It is important to diagnose PCs before surgery, not intraoperatively, in order to avoid unnecessary surgeries or superfluous excision of part of the thyroid gland and prevent the patient from iatrogenic hypothyroidism.A surgical approach is required in those patients with large-sized cysts, relapses despite needle aspirations or if it causes hyperparathyroidism.We describe a case report of a patient, initially misdiagnosed with a thyroid cyst swelling, who instead had a giant non-functioning PC, which produced dyspnoea or dysphagia.

Imaging of Treated Thyroid and Parathyroid Disease.

The thyroid and parathyroid glands are endocrine structures located in the visceral space of the infrahyoid neck. Imaging plays a critical role in the evaluation of patients with thyroid cancer, both in the pre and posttreatment setting. Disorders of thyroid function, that is, hyperthyroidism and hypothyroidism, are also fairly common, although imaging utilization is less frequent with these conditions. Parathyroid dysfunction results in disordered calcium metabolism. Imaging is frequently applied in the preoperative assessment of these patients undergoing parathyroidectomy; however, routine imaging in the postoperative setting is uncommon. Parathyroid carcinoma is rare; however, imaging may be used in the pre and posttreatment setting.

Is extensive surgery really necessary in patients with parathyroid carcinoma? Single-centre experience and a brief review of the literature.

AIM: Parathyroid carcinoma (PC) represents a rare cause of primary hyperparathyroidism (PHPT). In this paper, among patients who underwent surgery for PHPT, we compared those with benign parathyroid disease with those affected by PC in terms of demographic and preoperative biochemical features. Moreover, we singularly described all 10 cases of PC treated at our Institution (including a case that occurred in a patient with tertiary hyperparathyroidism) and a brief review of the literature. MATERIAL AND METHODS: Patients undergoing surgery for PHPT in our Unit between 2003 and 2018 were retrospectively analysed. They were divided into two groups: Group A (benign parathyroid disease), Group B (PC). The case of PC that occurred in the patient with tertiary hyperparathyroidism was not included into the two groups. RESULTS: Three hundred and eight patients were included: 299 in Group A and 9 in Group B. The mean preoperative serum PTH value and mean preoperative serum calcium level were significantly higher in Group B than in Group A (P = 0.018, P = 0.027; respectively). Including the case of PC that occurred in the patient with tertiary hyperparathyroidism, 10 patients with PC were treated at our Institution. Among these, 3 underwent a re-exploration. Disease recurrence occurred in 1 (10%) patient, who developed a local recurrence and distant metastases. CONCLUSIONS: In the presence of PHPT characterized by particularly high preoperative levels of serum PTH and calcium this malignancy should be suspected. On the basis of our experience, we believe that extensive surgery is not always necessary. KEY WORDS: Hyperparathyroidism, Parathyroid carcinoma, Parathyroid surgery.

Rapid standardized operating rooms (RAPSTOR) in thyroid and parathyroid surgery.

OBJECTIVE: To evaluate the impact of a high efficiency rapid standardized OR (RAPSTOR) for hemithyroid/parathyroid surgery using standardized equipment sets (SES) and consecutive case scheduling (CCS) on turnover times (TOT), average case volumes, patient outcomes, hospital costs and OR efficiency/stress. METHODS: Patients requiring hemithyroidectomy (primary or completion) or unilateral parathyroidectomy in a single surgeon's practice were scheduled consecutively with SES. Retrospective control groups were classified as sequential (CS) or non-sequential (CNS). A survey regarding OR efficiency/stress was administered. Phenomenography and descriptive statistics were conducted for time points, cost and patient outcome variables. Hospital cost minimization analysis was performed. RESULTS: The mean TOT of RAPSTOR procedures (16 min; n = 27) was not significantly different than CS (14 min, n = 14) or CNS (17 min, n = 6). Mean case number per hour was significantly increased in RAPSTOR (1.2) compared to both CS (0.9; p < 0.05) and CNS (0.7; p < 0.05). Average operative time was significantly reduced in RAPSTOR (32 min; n = 28) compared to CNS (48 min; p < 0.05) but not CS (33 min; p = 0.06). Time to discharge was reduced in RAPSTOR (595 min) compared to CNS (1210 min, p < 0.05). There was no difference in complication rate between all groups (p = 0.27). Survey responses suggested improved efficiency, teamwork and workflow. Furthermore, there is associated decrease in direct operative costs for RAPSTOR vs. CS. CONCLUSION: A high efficiency standardized OR for hemithyroid and parathyroid surgery using SES and CCS is associated with improved efficiency and, in this study, led to increased capacity at reduced cost without compromising patient safety. LEVEL OF EVIDENCE: Level 2.

Complete portal robotic resection of a giant mediastinal parathyroid cyst; A case report.

Parathyroid cysts (PCs) are rare, benign, cystic lesions, and PCs that occur in the mediastinum (mediastinal parathyroid cysts [MPCs]) are even more rare. Surgical resection is recommended as the first choice of treatment for MPCs. Sternotomy, thoracotomy, and thoracoscopic approaches are the most common methods for resection of MPCs. Herein, we report a case of robotic right portal minimally invasive resection of a giant nonfunctional MPC in the right anterosuperior mediastinum.

Impact of psychiatric comorbidities on outcomes related to thyroid and parathyroid operations.

BACKGROUND: We examined the effect of psychiatric comorbidities on perioperative surgical outcomes and the leading causes of readmissions in patients who underwent thyroid and parathyroid operations. METHOD: Patient information was retrieved from the Nationwide Readmission Database (2010-2017). Multivariate analysis was used to identify predictors for hospital readmissions. RESULTS: A total of 181,007 and 53,808 patients underwent thyroid and parathyroid operations, respectively. Of those, 8,468 (4.7%) and 6,112 (11.4%) patients were readmitted within 30 days. Psychiatric comorbidities were more frequent in readmitted cohorts after thyroidectomies (14.9% vs 10.4%; P < .001) and parathyroidectomies (16.8% vs 11.5%; P < .001), with anxiety being the most frequent cause (thyroid: 7.87%, parathyroid: 6.8%). Psychiatric comorbidities were associated with greater risk of in-hospital mortality (thyroid: odds ratio = 2.07, 95% confidence interval = 1.13-3.53; P = .015 and parathyroid: odds ratio = 1.67, 95% confidence interval = 1.04-2.70; P = .005), postoperative complications (thyroid: odds ratio = 1.528, 95% confidence interval = 1.473-1.585; P < .001 and parathyroid: odds ratio = 3.26, 95% confidence interval = 2.84-3.73; P < .001), prolonged duration of stay (thyroid: beta coefficient = 1.142, 95% confidence interval = 1.076-1.207; P < .001 and parathyroid: beta coefficient = 2.15, 95% confidence interval = 1.976-2.32; P < .001), and 30-day readmissions (thyroid: hazard ratio = 1.18, 95% confidence interval = 1.03-1.18; P = .047 and parathyroid: hazard ratio = 1.23, 95% confidence interval = 1.11-1.36; P < .001). Psychosis had the greatest risk of readmission (thyroid: hazard ratio = 1.51 and parathyroid: hazard ratio = 1.42), and dementia (odds ratio = 2.58) had the greatest risk of postoperative complications. CONCLUSION: Concomitant psychiatric conditions after thyroid and parathyroid operations were associated with increased risk of postoperative complications, prolonged hospital stays, and greater rates of readmissions.

Intraoperative near-infrared imaging of parathyroid glands: A comparison of first- and second-generation technologies.

BACKGROUND: Intraoperative near-infrared imaging (NIFI) of parathyroid glands (PG) by first-generation technology had limited image quality and depth penetration. Second-generation NIFI has recently been introduced. Our aim was to compare (1) capability to detect PG and (2) image quality between older and newer technologies. METHODS: Accurately detecting PG, as well as, quality of autofluorescence (AF) was compared between an older charge-coupled device (CCD) camera and a newer complementary metal-oxide semiconductor (CMOS). χ2 , t test, and analysis of variance were used for analysis. RESULTS: There were 300 patients who underwent parathyroidectomy (PTX) and/or thyroidectomy (THY) with NIFI, 200 with CCD, and 100 with CMOS. Although both NIFI technologies detected >94% of PG, CMOS was superior to CCD. Comparing AF quality, mean pixel intensity of PG compared with the background was higher with CMOS compared with CCD. When comparing PG detected by NIFI before visual identification by a surgeon, both CCD and CMOS had similar results (25% vs. 22%; p = .3). CONCLUSION: Both NIFI cameras were excellent at detecting PG. Second-generation NIFI (CMOS) displayed higher detection rates and AF intensity. Although surgeons identified majority of PG before NIFI detection, 25% of PG were identified with NIFI first, suggesting future advancements of this technology may expand its applications during parathyroid/thyroid operations.

Parathyroid cyst: differential diagnosis.

Parathyroid cysts are rare lesions of the cervical region and less frequently of the mediastinum. They occur mostly in women and are usually asymptomatic. They generally occur in the fourth and fifth decades of life and mainly are non-functioning. They commonly present as a neck mass that is found incidentally during surgery or in imaging test. Its importance lies in the difficulty in diagnosis, often confusing itself with thyroid pathology. The diagnosis is usually made intraoperatively, confirmed by histopathological examination.The aim of this paper is to report a case of parathyroid cyst that mimics a thyroid nodule.

Parathyroid 4D CT: What the Surgeon Wants to Know.

Parathyroid four-dimensional (4D) CT is an increasingly used and powerful tool for preoperative localization of abnormal parathyroid tissue in the setting of primary hyperparathyroidism. Accurate and precise localization of a single adenoma facilitates minimally invasive parathyroidectomy, and localization of multiglandular disease aids bilateral neck exploration. However, many radiologists find the interpretation of these examinations to be an intimidating challenge. The authors review parathyroid 4D CT findings of typical and atypical parathyroid lesions and provide illustrative examples. Relevant anatomy, embryology, and operative considerations with which the radiologist should be familiar to provide clinically useful image interpretations are also discussed. The most important 4D CT information to the surgeon includes the number, size, and specific location of candidate parathyroid lesions with respect to relevant surgical landmarks; the radiologist's opinion and confidence level regarding what each candidate lesion represents; and the presence or absence of ectopic or supernumerary parathyroid tissue, concurrent thyroid pathologic conditions, and arterial anomalies associated with a nonrecurrent laryngeal nerve. The authors provide the radiologist with an accessible and practical approach to performing and interpreting parathyroid 4D CT images, detail what the surgeon really wants to know from the radiologist and why, and provide an accompanying structured report outlining the key information to be addressed. By accurately reporting and concisely addressing the key information the surgeon desires from a parathyroid 4D CT examination, the radiologist substantially impacts patient care by enabling the surgeon to develop and execute the best possible operative plan for each patient. ©RSNA, 2020.

Pediatric parathyroid disease.

Parathyroid glands are critical for calcium and phosphate homeostasis. Parathyroid disease is relatively rare in the pediatric population, but there are some important pediatric-specific considerations and conditions. This article reviews parathyroid physiology, disorders of hyper- and hypo- function, operative management, and uniquely pediatric diagnoses such as neonatal severe hyperparathyroidism. Advances in preoperative imaging, intra-operative gland identification, and management of post-thyroidectomy hypocalcemia are also presented in detail. This article combines a review of fundamentals with recent advances in care, emphasizing pediatric-specific publications.

Preoperative Risk Index Among Patients Undergoing Thyroid or Parathyroid Surgery.

Importance: Frailty represents a multidimensional syndrome that is increasingly being used to stratify risk in surgical patients. Current frailty risk models are limited among those undergoing thyroid or parathyroid surgery. Objective: To develop and compare preoperative risk indices to determine factors associated with short-term major postoperative adverse events in patients undergoing thyroid or parathyroid surgery. Design, Setting, and Participants: This cohort study evaluated 154 895 patients in the American College of Surgeons National Surgical Quality Improvement Program who underwent thyroid or parathyroid surgery from January 1, 2007, to December 31, 2016. Exposures: Preoperative frailty-related and surgical factors from a derivation cohort were evaluated using simple and multiple logistic regression. Variables potentially associated with postoperative adverse events were subsequently combined into a personalized preoperative Cervical Endocrine Surgery Risk Index (CESRI) and compared with existing risk models using the validation cohort. Main Outcomes and Measures: Composite variable of any major postoperative adverse event, including death, within 30 days of surgery. Results: Of the 154 895 operations reviewed, 3318 patients (2.1%; 2296 women and 1022 men; mean [SD] age, 56.1 [15.6] years) experienced a major postoperative adverse event, with 163 deaths (0.1%). Older age (age, ≥80 years: odds ratio [OR], 2.35; 95% CI, 1.74-3.13), inpatient status (OR, 3.55; 95% CI, 3.08-4.11), male sex (OR, 1.49; 95% CI, 1.29-1.71), current tobacco smoking (OR, 1.25; 95% CI, 1.05-1.48), dyspnea (OR, 1.58; 95% CI, 1.29-1.91), recent weight loss (OR, 1.88; 95% CI, 1.23-2.78), functional dependence (OR, 2.77; 95% CI, 2.05-3.69), obesity (OR, 1.33; 95% CI, 1.10-1.60), anemia (OR, 2.14; 95% CI, 1.82-2.52), leukocytosis (OR, 1.73; 95% CI, 1.38-2.14), hypoalbuminemia (OR, 1.87; 95% CI, 1.56-2.23), use of anticoagulation (OR, 2.16; 95% CI, 1.64-2.81), and length of surgery (>4 hours: OR, 2.92; 95% CI, 2.37-3.59) were independently associated with major adverse events or death on multiple regression analysis (C statistic, 0.77; 95% CI, 0.76-0.78). The area under the curve of the CESRI to determine major adverse events, including death, using the validation cohort was 0.63 (95% CI, 0.61-0.64), with a sensitivity of 0.66 (95% CI, 0.64-0.68) and specificity of 0.66 (95% CI, 0.65-0.66). The CESRI outperformed other risk models for determining adverse events (CESRI vs 5-Factor Modified Frailty Index: delta C index, 0.11; 95% CI, 0.09-0.13; CESRI vs American Society of Anesthesiologists Physical Status Classification System: delta C index, 0.05; 95% CI, 0.03-0.07; CESRI vs American College of Surgeons Risk Calculator: delta C index, 0.02; 95% CI, 0.01-0.03; and CESRI vs Head and Neck Surgery Risk Index: delta C index, 0.04; 95% CI, 0.03-0.06). Conclusions and Relevance: This study suggests that the CESRI is able to determine major postoperative adverse events in patients undergoing thyroid or parathyroid surgery.