3. o Enlarging non-tender anterior
neck mass
o No dyspnea, no hoarseness
o No consult was done
3 YEARS PTA
2 YEARS PTA
2 MONTHS
PTA
1 WEEK PTA
ADMISSION
4. o Intermittent Joint Pains on both
elbows and knees
o 7/10
o Bilateral flank pain
o No fever, no hematuria, no dysuria
o No consult done
3 YEARS PTA
2 YEARS PTA
2 MONTHS
PTA
1 WEEK PTA
ADMISSION
5. o Progressive enlargement of the
anterior neck mass and worsening of
the joint pains
3 YEARS PTA
2 YEARS PTA
2 MONTHS
PTA
1 WEEK PTA
ADMISSION
6. o Joint Pain 8/10
o 5 pounds unintentional weight loss
o Persistence of flank pain
o Sought consult with a urologist
o STAGHORN CALCULI
o s/p DJ Stent Insertion, Bilateral
3 YEARS PTA
2 YEARS PTA
2 MONTHS
PTA
1 WEEK PTA
ADMISSION
7.
8. o Joint Pain 8/10
o 5 pounds unintentional weight loss
o Persistence of flank pain
o Sought consult with a urologist
o STAGHORN CALCULI
o s/p DJ Stent Insertion, Bilateral
o Advised to consult an endocrinologist
3 YEARS PTA
2 YEARS PTA
2 MONTHS
PTA
1 WEEK PTA
ADMISSION
9. o Difficulty walking
o Unable to stand for a long period
3 YEARS PTA
2 YEARS PTA
2 MONTHS
PTA
1 WEEK PTA
ADMISSION
10. o Consulted a private endocrinologist
o THYROID FUNCTION TEST
o Normal
o SERUM IONIZED CALCIUM
o Elevated
o BONE DEXA SCAN
o Osteoporosis
3 YEARS PTA
2 YEARS PTA
2 MONTHS
PTA
1 WEEK PTA
ADMISSION
11.
12. o SESTAMIBI SCAN
o Enlarged right parathyroid with
substernal extension
o Hyperfunctioning
3 YEARS PTA
2 YEARS PTA
2 MONTHS
PTA
1 WEEK PTA
ADMISSION
13.
14.
15.
16. o SESTAMIBI SCAN
o Enlarged right parathyroid with
substernal extension
o Hyperfunctioning
o CT SCAN
o Large soft tissue mass
o 11.8 x 5.9 x 5 cm
o right thoracic inlet and superior and
middle mediastinum
3 YEARS PTA
2 YEARS PTA
2 MONTHS
PTA
1 WEEK PTA
ADMISSION
17. o SESTAMIBI SCAN
o Enlarged right parathyroid with
substernal extension
o Hyperfunctioning
o CT SCAN
o Large soft tissue mass
o 11.8 x 5.9 x 5 cm
o right thoracic inlet and superior and
middle mediastinum
o She was advised surgery, hence,
admission
3 YEARS PTA
2 YEARS PTA
2 MONTHS
PTA
1 WEEK PTA
ADMISSION
18. REVIEW OF SYSTEMS
General Survey: (+) weight loss, (+) weakness, (-) loss of appetite
Cutaneous: (+) pallor, (-) itchiness, (-) jaundice, (-) abnormal hair or
nail growth, (-) erythematous
Eye: (-) blurring of vision, (-) lacrimation, (-) pain
Ear: (-) tinnitus, (-) discharge, (-) deafness, (-) otalgia
Nose: (-) epistaxis, (-) discharge, (-) obstruction, (-) abnormal sense of
smell, (-) postnasal drip, (-) sinus pain
Mouth: (-) gum bleeding, (-) mouth sores, (-) fissures
Throat: (-) soreness, (-) tonsillar pain, (-) dysphagia, (-) odynophagia
Neck: (-) neck stiffness, (-) limitation of motion
20. PAST MEDICAL HISTORY
Previous Illnesses/hospitalizations:
(+) Leptospirosis (1989)
(+) Multinodular nontoxic goiter
(-) HTN
(-) DM
(-) MI/Stroke
(-) Asthma
(-) PTB
(-) Pneumonia
Known allergies: none
Previous accidents/surgeries:
DJ stent insertion (2019)
Current Medications:
Ferrous Sulfate + Folic acid
21. FAMILY HISTORY
(+) Hypertension- Father
(+) DM- Sister, aunt
(+) Goiter- Cousin
(+) Emphysema- Father
(-) pneumonia, TB
(-) cirrhosis
(-) stroke
SOCIAL HISTORY
• Non-smoker; exposed to second
hand smoking
• Non-alcoholic beverage drinker
• Denies Illicit Drug Use
32. PARATHYROID GLAND
• Usually four parathyroid glands
• Ovoid in shape, measuring 5-7 mm, and weighing
40-50 mg
• Superior glands more consistent in position
(dorsal to RLN)
• Inferior glands more variable in position
(ventral to RLN)
• Supplied by superior and inferior thyroid arteries
• Yellow-brown tissue similar to surrounding fatty
tissue
• Contains mainly chief cells which produce
parathyroid hormone (PTH)
33. PARATHYROID HORMONE (PTH)
Synthesized by the parathyroid glands
Bone
• Stimulates osteoclasts
• Inhibits osteoblasts
Kidney
• Increases reabsorption of calcium
• Increases phosphate excretion
GI tract
• Stimulates hydroxylation of 25-OH D
1,25 OH D
• 1,25 OH D increases the intestinal
absorption of dietary calcium and
phosphate
34. DISORDERS OF THE
PARATHYROID GLANDS
Pathophysiology Clinical Manifestations Management
Primary Hyperparathyroidism
Increased PTH from abnormal parathyroid
glands
Results from enlargement of a single gland or
parathyroid adenoma (80%), multiple
adenomas or hyperplasia (15-20%), and
parathyroid carcinoma (1%)
Classic Pentad
• Kidney stones
• Painful bones
• Abdominal groans
• Psychic moans
• Fatigue overtones
Symptomatic: parathyroidectomy
Secondary Hyperparathyroidism
Increased response to hypocalcemic states Calciphylaxis: painful, violaceous
lesions on the extremities
Medical: cinacalcet (calcimimetic)
Parathyroidectomy: if PTH remains high
Tertiary Hyperparathyroidism
Autonomously functioning parathyroid glands
after correction of underlying disorder in
secondary hyperparathyroidism
Similar to primary
hyperparathyroidism
Medical: cinacalcet (calcimimetic)
Parathyroidectomy: if symptomatic or if with
persistence of elevated PTH >1 year after kidney
transplantation
Hypoparathyroidism
Most common: surgically induced Chvostek sign, Trousseau sign Medical: calcium and vitamin D supplementation
35. PARATHYROID ADENOMA
Epidemiology
• Single parathyroid adenoma (80-85%)
• Double adenoma (4-5%)
• Parathyroid hyperplasia in (10-12%)
Histopathology
• Primarily composed of chief cells
• May have a rim of normal parathyroid
tissue surrounding the adenoma
• Microadenomas are unencapsulated
while larger tumors may have a thin
fibrous capsule present with cystic
degeneration
36. PARATHYROID ADENOMA
Clinical presentation
• Asymptomatic with hypercalcemia
incidentally discovered on routine lab
work
• Symptomatic commonly manifesting as
symptoms of hypercalcemia such as bone
pain, fatigue, polyuria, nephrolithiasis,
constipation, and neuropsychiatric
disturbance
Diagnostics
• Elevated serum calcium
• Ultrasound
• Technetium (Tc) Sestamibi
37. PARATHYROID ADENOMA
Management
• Bilateral 4-gland exploration
• Minimally invasive parathyroidectomy
Complications
• Untreated parathyroid adenoma:
parathyroid crisis (hypercalcemia >15
mg/dL)
• Resection of the parathyroid adenoma:
injury to the recurrent laryngeal nerve
38.
39. BACKGROUND
• Pre-operative localization has allowed for minimally invasive targeted surgical
approaches in cases of a single adenoma
• Patients with pre-operatively localized glands benefited from a targeted open
approach – Open Minimally Invasive Parathyroidectomy (OMIP)
• Endoscopic adaptation allowed for even smaller incisions – Minimally Invasive Video
Assisted Parathyroidectomy (MIVAP)
40. METHODS
GROUP B
GROUP A
Traditional parathyroidectomy with
BNE MIVAP with ioPTH
Exclusion Criteria
• Gland >3cm in size
• Family history of parathyroid disease
• Previous neck surgery
• Clinical suspicion for a parathyroid carcinoma or inflammatory thyroid condition
41. METHODS
• Pre and post-operative video laryngostroboscopy (VLS) for any voice changes
• Operative time: from incision to placement of dressing
• Pain evaluation: visual analogue scale (1 hour, 24 hours)
• Evaluation for cure
• 6 month follow up of Ca and PTH values
• Recurrence: Ca >10.5mg/dL and/or PTH >72 pg/mL
43. CONCLUSION
MIVAP with ioPTH demonstrated significantly improved operative times and
post-operative pain levels, while maintaining equivalent recurrence rates
