title: Utility of an intraoperative ultrasound in lateral approach mini-parathyroidectomy with discordant pre-operative imaging.
abstract: Objectives of this study were to assess the utility of intra-operative ultrasound to resolve discordant pre-operative imaging prior to a lateral approach mini-parathyroidectomy, by studying prospective case series in a head and neck endocrine unit. Patients with primary hyperparathyroidism due to a single adenoma with discordant pre-operative ultrasound and sestamibi were enrolled. They underwent a further intra-operative ultrasound by a head and neck radiologist with a view to proceed with a mini-parathyroidectomy. The main outcome measure was utility of intra-operative ultrasound compared to operative findings and pre-operative imaging. Secondary measures were complications of mini-parathyroidectomy, operative and ambulatory discharge time. Twenty-two patients underwent surgery with intra-operative ultrasound in the surgical position. The intra-operative ultrasound findings correlated with the operative findings in all cases (100 %). There were 16 inferior adenomas and 6 superior adenomas. Six inferior adenomas were in a retrosternal position, eight were obscured by benign thyroid lesions and a further two reported pre-operatively as superior. Three out of six superior adenomas were reported as inferior pre-operatively as the inferior thyroid artery was inadequately visualised, two were retro-carotid and one was retro-oesophageal. All patients were discharged within 23 h of surgery. There were no unsuccessful focused explorations. Histological analysis confirmed the adenomas. No morbidity (vocal cord palsy, haematoma, hungry bones) was noted. The results indicated that intra-operative ultrasound by a dedicated radiologist is a valuable tool in resolving discordance of pre-operative imaging. Appropriate patient positioning with neck extension and muscle relaxation allows placement of the probe in the obscure retro-carotid and retro-oesophageal locations and unmasks apparent "mediastinal" parathyroids facilitating focused dissection.
authors.affiliation: Department of Otolaryngology, Head and Neck Surgery, Addenbrooke's Hospital, Box 10, Cambridge, CB2 0QQ, UK. aklami@doctors.org.uk
authors.forename: Ali
authors.initials: A
authors.lastname: Al-Lami
authors.forename: Faruque
authors.initials: F
authors.lastname: Riffat
authors.forename: Furqan
authors.initials: F
authors.lastname: Alamgir
authors.forename: Raghav
authors.initials: R
authors.lastname: Dwivedi
authors.forename: Laurence
authors.initials: L
authors.lastname: Berman
authors.forename: Brian
authors.initials: B
authors.lastname: Fish
authors.forename: Piyush
authors.initials: P
authors.lastname: Jani
mesh_terms: D000236:Adenoma / Q000000981:diagnostic imaging* / Q000601:surgery*; D000465:Algorithms; D005260:Female; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000000981:diagnostic imaging* / Q000601:surgery*; D007432:Intraoperative Period; D008297:Male; D010282:Parathyroid Neoplasms / Q000000981:diagnostic imaging* / Q000601:surgery*; D016105:Parathyroidectomy / Q000379:methods*; D011446:Prospective Studies; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi; D016896:Treatment Outcome; D014463:Ultrasonography
chemical_list: D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi