The document describes a case presentation at the TCVS Conference on October 10, 2019 by clinical clerks Alexander Xerxes Malicse and Jessica Martinez. It details the history of a 54-year-old Filipino man who presented with a large anterior neck mass, joint pains, flank pain, and difficulty walking over several years. Various tests revealed primary hyperparathyroidism secondary to a parathyroid adenoma, multinodular nontoxic goiter, and chronic kidney disease from hypercalcemia. The patient was admitted for cystoscopy, DJ stent replacement, total thyroidectomy, parathyroidectomy, and sternotomy to remove the enlarged right parathyroid gland.

1. TCVS
CONFERENCE
OCTOBER 10, 2019
CLINICAL CLERK ALEXANDER XERXES MALICSE
CLINICAL CLERK JESSICA MARTINEZ

2. OSG 54/F
Married, Filipino
Roman Catholic
CC: Difficulty in Walking

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

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

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

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

19. REVIEW OF SYSTEMS
Cardiology: (-) easy fatigability, (-) orthopnea, (-) PND, (-) palpitations
Respiratory: (+) cough, (-) shortness of breath, (-) increase in respiration
Gastrointestinal: (+) dark stool, (-) nausea, (-) vomiting, (-) hematemesis,
(-) hematochezia, (-) abdominal pain, (-) diarrhea
Endocrine: (+) polyuria, (-) polydipsia, (-) polyphagia
Genitourinary: (+) nocturia, (-) frequency, (-) urgency, (-) hesitancy
Neurologic: (-) limb numbness, (-) dizziness, (-) paresthesia, (-) seizures, (-)
paralysis
Psychiatry: (-) anxiety, (-) depression, (-) hallucination, (-) paranoia
Musculoskeletal: See HPI
Hematologic: (-) abnormal bleeding, (-) bruising

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

22. PHYSICAL EXAM
GENERAL SURVEY: Conscious, coherent, not in respiratory distress,
ambulatory, GCS 15 (E4V5M6)
VITAL SIGNS: BP:120/80 HR: 72 RR:22 Temperature: 36.8 O2 sat: 99%
Ht: 146cm Wt: 110 lbs
SKIN/CUTANEOUS: (+) pallor, (-) cyanosis, (-) jaundice
HEAD: evenly distributed hair, (-) facial deformities, (-) characteristic facies
EYES: (+) pale palpebral conjunctiva, (-) periorbital edema, (-) opacity of lens
EARS: (-) tragal tenderness, non-hyperemic EAC
NOSE: No gross deformities, midline septum, (-) discharge, (-) epistaxis
MOUTH: Dry lips, moist buccal mucosa, (-) oral ulcers, (-) oral plaques

24. PHYSICAL EXAM
NECK: (+) multinodular anterior neck mass, thyroid is enlarged, no palpable
cervical lymphadenopathies, no distended neck veins, (-) carotid bruit
RESPIRATORY: Symmetrical chest expansion, equal tactile and vocal fremiti, (-)
crackles
CARDIOVASCULAR: Adynamic precordium, apex beat at 5th LICS MCL, (-)
heaves, (-) thrills, (-) lifts, (-) murmur, soft S1 followed by loud S2 at base, loud
S1 followed by soft S2 at apex, pulses regular
GASTROINTESTINAL: soft, nontender abdomen, normoactive bowel sounds, (-)
abdominal bruit, tympanitic on all quadrants, (-) direct and rebound
tenderness
GENITOURINARY: (-) CVA tenderness
EXTREMITIES: (-) bipedal edema, ++ radial pulse, equal, CRT <2 sec

25. Primary Hyperparathyroidism Secondary
to Parathyroid Adenoma
Multinodular Nontoxic Goiter
CKD Stage 3B Secondary to
Hypercalcemia Secondary to Primary
Hyperparathyroidism
ADMITTING DIAGNOSIS

26. Cystoscopy, Retrograde Pyelography,
DJ Stent Replacement, Bilateral
Total Thyroidectomy, Parathyroidectomy,
Sternotomy,
PLAN

30. Cystoscopy, Retrograde Pyelography,
DJ Stent Replacement, Bilateral
Total Thyroidectomy; Sternotomy;
Parathyroidectomy, Right;
Extended Thymectomy
OR DONE

31. DISCUSSION

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

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

42. RESULTS
Operative times, post-operative pain levels, and complication rates compared
between group A and group B

43. CONCLUSION
MIVAP with ioPTH demonstrated significantly improved operative times and
post-operative pain levels, while maintaining equivalent recurrence rates

44. Thank you!