BackTable / ENT / Podcast / Transcript #85

Podcast Transcript: Surgical Management of Parathyroid Disease

with Dr. David Goldenberg and Dr. Dipan Desai

In this episode of BackTable, Dr. Ashley Agan and guest co-host Dipan Desai (Johns Hopkins) interview David Goldenberg (Penn State) about evaluation and surgical management of parathyroid disease. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Diagnosing Parathyroid Disease

(2) Criteria for Parathyroidectomy Surgery

(3) Preferred Imaging Studies for Parathyroidectomy

(4) A Surgical Guide to Parathyroidectomy

(5) Defining Success in Parathyroidectomy Procedures

(6) Locating Tricky Parathyroid Glands

(7) Parathyroid Carcinoma

(8) Post Operative Care

(9) Head and Neck Endocrine Surgery: A Comprehensive Textbook, Surgical and Video Atlas by Dr. David Goldenberg

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Surgical Management of Parathyroid Disease with Dr. David Goldenberg and Dr. Dipan Desai on the BackTable ENT Podcast)

Ep 85 Surgical Management of Parathyroid Disease with Dr. David Goldenberg and Dr. Dipan Desai

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[Dr. Ashley Agan]
Hey everybody. Welcome to the Back Table ENT podcast. My name's Ashley Agan, I'm a general ENT. Today, I'm joined by a special guest host, Dr. Dipan Desai. He's actually a former resident of ours here at UT Southwestern, and he's now the head and neck endocrine surgery fellow at Johns Hopkins. Welcome to the show, Dr. Desai.

[Dr. Dipan Desai]
Thanks, Ashley. I really appreciate being on the podcast and getting to join you guys for this awesome conversation today.

[Dr. Ashley Agan]
Today we're going to be talking about the surgical management of parathyroid disease. With us, we have Dr. David Goldenberg. He's a professor and chair of the Department of Otolaryngology at Pennsylvania State University in Hershey, Pennsylvania. He's a head and neck surgical oncologist. He's returning to the show after his first appearance in episode 35, in which we discussed thyroid nodules. If you haven't checked that one out, I recommend you go back and listen to that one as well. Welcome back to the show, Dr. Goldenberg.

[Dr. David Goldenberg]
Thank you very much for having me.

(1) Diagnosing Parathyroid Disease

[Dr. Ashley Agan]
All right. Just kicking it off, we're talking about the management of parathyroid disease. Just starting out, what are the symptoms that these patients are coming in with? What does your history look like? What symptoms are you expecting to see?

[Dr. David Goldenberg]
All of us in medical school were taught moans, bones, stones, and groans, where people came in with profound symptoms. Fortunately, we don't see those kinds of symptoms anymore. About 20 or 30% will come in with a history of kidney stones, but many of the patients have non-specific symptoms such as fatigue, mental fog, bone or abdominal pain, and poor sleep habits. Since primary hyperparathyroidism often occurs in perimenopausal women, oftentimes, those symptoms are dismissed and the patients find them very, very vexing. The good news is that parathyroid surgery actually cures many of these symptoms, if not all of them, and very quickly indeed.

[Dr. Ashley Agan]
Most of these patients when they're making their way to you, have they already been diagnosed from labs? Their primary care, somebody has picked it up and then they said, okay, we need to send you on to be further evaluated?

[Dr. David Goldenberg]
In my practice, the vast majority are sent to me either by primary care physician or an endocrinologist. Labs are actually the core of the diagnosis to have a diagnosis of primary hyperparathyroidism. Ideally, one will come in with an elevated serum calcium and elevated parathyroid hormone, and that's the core. There are other labs which are helpful, such as 24-hour urine calcium, which precludes the diagnosis of FHH and that's important. Another one is vitamin D is also important because people who are vitamin D deficient and have primary hyperparathyroidism typically are sicker. Their numbers are higher, and it should be addressed prior to surgery.

[Dr. Ashley Agan]
Then just to stop you, FHH being familial hypercalcemia?

[Dr. David Goldenberg]
Hypercalcemia, yes. I'm sorry.

[Dr. Ashley Agan]
It's okay. Just for listeners who may not know. Most people, you think, like primary care, are doing annual screening and maybe checking BMP and maybe vitamin D, and then if the calcium is high, then reflexively getting a PTH level. Is that typically how it works?

[Dr. David Goldenberg]
Unfortunately, oftentimes, a patient will come in with a long history of hypercalcemia that was being "watched." If things are done correctly, then the patient has elevated calcium and there are other reasons for elevated calcium. Those absolutely have to be ruled out. As a matter of fact, some of them are very serious, such as malignancy. Malignancy and primary hyperparathyroidism together are about 90%, 95% of all hypercalcemia. Once more serious things are ruled out and once certain drugs such as thiazides and lithium are ruled out as a cause, then yes, parathyroid hormone is done and the patients are sent on for definitive care.

[Dr. Dipan Desai]
Dr. Goldenberg, how do you approach a patient who's maybe borderline, they've maybe had an elevated calcium some time ago and their labs vary between the normal range and mildly elevated?

[Dr. David Goldenberg]
This is where some clinical decision-making comes in. It depends on their symptoms, it depends on their parathyroid hormone. There are certainly patients who come in thinking that they have hyperparathyroidism because they read on the internet the symptoms and their calcium and their parathyroid hormone are both normal or within the normal range. That's a conversation that's sometimes difficult. If a patient is, sometimes it's high, sometimes it's low, I may get them an imaging study to see if there is something there. There have been patients where I said, this has not declared itself quite yet. Let's get you another calcium in six months. It really does depend.

[Dr. Dipan Desai]
Obviously, we've been focusing mostly on primary hyperparathyroidism so far, and we won't delve fully, for the interest of time, into secondary or tertiary hyperparathyroidism, but how do you approach those patients and is there anything different in terms of your history or your physical exam?

[Dr. David Goldenberg]
Patients who have secondary or tertiary hyperparathyroidism, they come to us from nephrology, they're very sick, typically. Their calcium does not always have to be elevated, parathyroid hormone can be very elevated. Secondary hyperparathyroidism if possible should be treated medically, it's only the patients who are refractory who come to surgery. Those patients will obviously get a far more extensive dissection and exploration.

(2) Criteria for Parathyroidectomy Surgery

[Dr. Dipan Desai]
For your standard primary hyperparathyroidism patient, what are your criteria for taking them to surgery?

[Dr. David Goldenberg]
There's the old NIH criteria for parathyroidectomy if symptomatic with serum calcium, life-threatening, et cetera, et cetera. Like I said at the beginning, the vast majority of patients who we see do have symptoms, they are just vague or non-specific but they're there and they really do bother the patient. In my mind, if the patient has a localizing study and if they have blood work which is indicative, then they're going to surgery. I do have very few patients who are actually symptom-free and they obviously have an adenoma. They too probably, I would take them to surgery as well.

[Dr. Ashley Agan]
Just to back up, so most patients who have primary hyperparathyroidism have a single parathyroid adenoma that is causing that, would you say?

[Dr. David Goldenberg]
The vast majority. The vast majority of patients have a single adenoma, and then there are about 15 to 25% who will have more than one abnormal gland. There is such a thing as a double adenoma. More often they will have four-gland hyperplasia, in which case all four of the glands need to be addressed. Rarely, and I say incredibly rare, there's 1%, there's a parathyroid carcinoma.

[Dr. Ashley Agan]
Interesting. With the four-gland hyperplasia, so with that, there's not an adenoma. All four glands are just hyper-functioning, is that the right way to think about it?

[Dr. David Goldenberg]
Correct. Yes. That's exactly what it is. All four glands are hyper-functioning and they're tricking the body into thinking that it needs more calcium in the blood and it leeches it obviously from the bone. Patients will develop osteopenia and ultimately osteoporosis if they don't get it taken care of.

[Dr. Ashley Agan]
With four-gland hyperplasia, do we know what the underlying issue is? Why does that happen? Is that perimenopausal as well? Is that patient demographic different?

[Dr. David Goldenberg]
Not really. It should be the same mechanism. It just affects all four glands. It is obviously a lot less common. To my knowledge, it's the same demographic. It's not that men can't get this, it's just that more often it's a woman's disease and those are the age group.

[Dr. Ashley Agan]
Got you.

(3) Preferred Imaging Studies for Parathyroidectomy

[Dr. Dipan Desai]
Then how do you go about elucidating what type of disease they have, whether it's an adenoma or four gland disease in terms of imaging studies or any other evaluation prior to surgery?

[Dr. David Goldenberg]
There are studies that say that actually when, and this is counterintuitive, that if people have multigland disease that their parathyroid hormone is actually lower. All of my patients will get at least one imaging modality if they've not had it done beforehand. If I'm convinced that the patient has primary hyperparathyroidism and their localization imaging or images do not localize anything, then that's the assumption that we go on that they have multi-gland disease.

[Dr. Dipan Desai]
What are the imaging studies that you prefer?

[Dr. David Goldenberg]
Because of the way patients are referred to us from the outside and they come into a tertiary medical center, oftentimes the patient comes with something already done. Sometimes it's adequate and sometimes it's not. If I'm the person working the patient up, I go with a four-dimensional CAT scan. I've been doing this for a while and this has evolved over time. First, I did Ultrasounds in the office and then I was doing CT scans and now, I believe that the four-dimensional CAT scan is the most accurate for my practice. I don't typically do double scans as proof of the disease. There are those who do, if they say that if you have two concurrent modalities that show this, then you know you have your diagnosis. I personally don't do this. I go with the imaging in the lab.

[Dr. Ashley Agan]
Can you elaborate on what a 4D CT scan is?

[Dr. David Goldenberg]
A 4D CT scan is a lot less cool than it sounds. When I first heard of it, I thought it would be spinning and holograms. There's none of that. It's basically a thinly sliced CAT scan with multiple phases of arterial and venous contrast and some nifty software which allows you to differentiate between parathyroid adenomas, lymph nodes, the thyroid gland. It also gives you some really nifty imaging of the arterial blood supply to the parathyroids and that also helps find adenomas.

We have to remember that the size of a normal parathyroid is the size of a grain of rice and there is no imaging modality to date that can see a normal parathyroid. That being said, a parathyroid adenoma can be maybe the size of a raisin. They can be bigger too, but oftentimes they're not all that impressive when you get them out. It's nice to wear loops because they look really big to you when you're taking them out, but they really are not that big.

[Dr. Dipan Desai]
Can you talk a little bit about the pros and cons of the alternative imaging modalities, either in-office Ultrasound or SPECT CT scans?

[Dr. David Goldenberg]
Sure. Ultrasound is wonderful. As long as the adenoma is at the threshold or above the threshold of detection, size-wise, then it's great. You see a hypoechoic nodule. If it's an inferior parathyroid, typically you'll see it, it's extra thyroidal, it's hypoechoic. Upper parathyroid adenomas are easier to-- You can see, again, extra thyroidal hypoechoic, and then you see a thyroid tissue above it on the longitudinal scan, great. The problem is the two enemies of Ultrasound are air and bone.

If it's below the clavicles, if it's an elderly person, if it's below the manubrium, if it's behind the airway, you're not going to see it. A SPECT scan, PA SPECT scan is injection of technetium and has a different washout time. Nowadays most people are doing a SPECT CT scan fused where you have functional anatomic data at the same time superimposed one upon the other. The technetium stays behind in the adenoma when it washes out of the thyroid gland and the CAT scan shows you anatomically where it is and you put them together and you get a nice little area in either orange or blue that's illuminated very nicely.

It will not see very small adenomas, and it also is a little weaker in flat adenomas. This is anecdotal, this is what I've seen when I was doing, if the adenoma is flattened against the back of the thyroid gland, sometimes it won't be seen. Like I said, the four-dimensional CAT scan has been great. If someone comes in with a scan and it's non localizing, I certainly will get them another scan in our institution. It's important if you're doing this kind of surgery that you feel comfortable reading these scans yourself, and I do, I do get radiology's input, but they're quite a few times where they've said there's nothing there and I thought there was, and in the end, surgery proves whether you're right or wrong.

(4) A Surgical Guide to Parathyroidectomy

[Dr. Ashley Agan]
Yes. I imagine the straightforward cases come in, they have hypercalcemia, they have hyperparathyroidism, they have a scan that has a localizing lesion where you're like, "Ah, there it is right there." Then you talk to the patient about surgery. What about the patients who are not as clear cut? What if the scan is not showing anything, but your labs are really suggesting that there is something, how do you approach that?

[Dr. David Goldenberg]
That's a great question. If I'm convinced and the patient is on board with having a surgery, I will explain to them what the issue is and it didn't localize, but I am convinced that there is a problem here and it can be fixed surgically. Then typically we'll do an exploration and evaluate all four parathyroids and decide which one or ones are the offending parathyroids in that person's case.

[Dr. Ashley Agan]
If the first scan doesn't show anything, do you at least get two scans that are not showing anything before you go to surgery? Or will you ever have one scan and then talk about it and do four gland exploration just based on that? Let's say it's a 4D CT, it's the best that you can do.

[Dr. David Goldenberg]
If a person comes in, if they don't have a 4D CT scan and nothing is localized, they're getting a 4D scan in our institution before we move forward. If the patient comes in and they've tried everything and it's been done someplace and I read the scans and the radiologist read the scans and we're convinced there is nothing, I typically won't get them a third. If they have a SPECT CT and a 4D CT, I'm not going to get them an Ultrasound. They'll probably go straight to surgery. It really depends on how comfortable I am with the pre-preoperative localization imaging. It's not-- We will go over those scans even from the outside and sometimes I don't agree and I say, "You know what? It's not convincing, but I think there's something on the left lower one." That's the way I'll start it." The patient has to be aware that this may end with a four-gland exploration.

[Dr. Dipan Desai]
Once you've decided to take the patient to the operating room, can you talk a little bit about what are your cutoffs for considering the surgery of success and if you use intraop-parathyroid hormone testing to help guide you?

[Dr. David Goldenberg]
If the parathyroid is like a chip shot and it's big and you know where it is and you take it out, that's great, but I routinely use intraoperative rapid PTH and conventional wisdom is if you have a drop in 50%, then it's considered successful. That's supposedly 10 minutes. I typically wait 15 just because sometimes there's some manipulation of the gland and I just want to make sure that the drop is a drop.

There are cases where the patient comes in with parathyroid hormone, which is not all that high, and it's even borderline high and 50% would take it very, very low. That's again, where clinical judgment comes in. If I'm sure that I got the offending parathyroid or parathyroids and the hormone has dropped, but it's not exactly 50%. There have been times where I've said, okay, that's it. We got what we needed to do.

[Dr. Ashley Agan]
Can you talk a little bit about the actual surgical approach and technique?

[Dr. David Goldenberg]
Sure. If this is a first-time parathyroid and we know where it is, I approach this much like I do a thyroidectomy. We make a very small incision about the level of a coker incision, so two fingerbreadths above the clavicles in the midline. It's about an inch, a little more than an inch and a half. We move the strap muscles aside, medialize the thyroid gland. If I know where it is and it's lower parathyroid, then sometimes you don't have to take the middle thyroid vein, but oftentimes you do to adequately mobilize the thyroid gland and then we find the parathyroid.

If I'm doing a focus parathyroidectomy, then we just remove it and wait and measure the parathyroid hormone. If it's an upper parathyroid, it's very important to remember that the upper parathyroid is in close proximity to the recurrent laryngeal nerve and you have to be careful. Sometimes it's not uncommon to have it right adjacent to the nerve. If I'm doing a four-gland exploration, it's a little bit different. Their conventional wisdom says that you find all four parathyroids before you touch any of them.

The reason you do that is, you're saying, "Oh, I'm sure it's this one." Then you find one on the other side that's even bigger and then you find yourself leaving the OR with the patient missing two unnecessarily. I typically do not use frozen section as a test for the parathyroid itself but there are times where a patient has a grape like multinodular goiter with these little nodules falling off adjacent to and you don't know if you have a little piece of parathyroid or a little piece of thyroid gland. In those cases, the frozen section is helpful. In my practice if I do a focused parathyroidectomy, the patient's closed up and they go home the same day. If I do an exploration, I treat it like a thyroidectomy and I keep those patients for 23 hours.

[Dr. Ashley Agan]
You're identifying the recurrent laryngeal nerve when you are addressing a superior parathyroid adenoma then if it's inferior, you don't necessarily need to go look for it?

[Dr. David Goldenberg]
You don't necessarily. I typically do. I think it's really healthy for the residents to feel comfortable doing that. We do find it every time. I don't really know. It is the gold standard during thyroid surgery. I don't know that I've read it particularly for parathyroid surgery. We typically find it. My point was that the upper parathyroid is there, that's right where the nerve crosses or the nerves just come to, but lower parathyroid, you can do a lower parathyroidectomy and not encounter the nerve at all because it's variable.

[Dr. Dipan Desai]
Are you using nerve monitoring for all of these cases?

[Dr. David Goldenberg]
Every time. Every case, every time.

[Dr. Ashley Agan]
Yes. It makes sense. Any pearls as far as identifying parathyroid glands without damaging their blood supply, especially with the normal ones being so tiny.

[Dr. David Goldenberg]
Yes, that is a great point and I'm sure Dipan will concur that loops are helpful. You know that they get their blood supply from the inferior thyroid artery, typically both of them. Not always, but typically, and it's gentle handling of tissue. These are tiny little glands. Blunt dissection is done gently. One of the points that people have been taught for as long as they've been doing parathyroid surgery is the fact that you want to keep this bloodless because blood stains the parathyroid. Parathyroids have a different color than any of the surrounding fat.

If you look at it closely, they say it's ochre, it's more brown than fat and it's really important to be able to see these nuances so the entire dissection should be meticulous and bloodless. When you pick up a parathyroid, you never grab the gland itself. You always grab the fat cap if you're grabbing it all. If you can do it without grabbing, that's wonderful. You can see the blood supply often, and you really have to-- as you alluded to, you have to be very careful because there's no point in leaving a dead parathyroid behind because you took out the tiny arterial supply.

[Dr. Dipan Desai]
It's funny you mentioned that. I feel like I've heard a lot of different descriptions for the color of a parathyroid, but almost always food related, either salmon colored or nutmeg and I find that of variable use but super subtle sometimes. Then once you've identified potentially you're offending glands or if you're doing a four gland hyperplasia case, all four glands. Can you talk us through your decision making on how much to remove and which glands you remove and what you choose to leave behind?

[Dr. David Goldenberg]
Well, sometimes it's really hard to tell. I have taken biopsies of each gland and asked if they were hypercellular. I've looked at them closely. There are those who say to leave the lower one because the blood supply is more robust. If you're going to leave, leave a lower one. You have to look at all four of them and evaluate which ones look the most abnormal, and you start with that. If both lower ones are frankly abnormal, they're the first ones to go. If I can save a lower one because the upper ones are abnormal or more abnormal looking then I will do that. It really is nuanced. I wish I had some real guidance there. There needs to be a little bit of clinical decision making.

(5) Defining Success in Parathyroidectomy Procedures

[Dr. Dipan Desai]
If you are treating a four-lane hyperplasia or a secondary parathyroidism case, are you typically taking three or three and a half or is that not always a fixed rule?

[Dr. David Goldenberg]
Yes, between three and three and a half and I do follow the parathyroid hormone. There have been times that I've left three and it's done our job. There have been times where even that doesn't do it.

[Dr. Dipan Desai]
I see. Can you talk through when you draw those labs, you said, I know up to 15 minutes out, but what are the time points?

[Dr. David Goldenberg]
I draw labs 15 minutes after removal of whatever I'm looking after. I've had cases earlier in my career where 10 minutes just didn't cut it and so I just decided on 15, there are people who do 20 as well. I don't know about how it is at Hopkins now with Rapid PTH, in my institution it isn't as rapid as its name. There's a lot of waiting around, singing campfire songs while we wait for the parathyroid hormone to come back.

[Dr. Dipan Desai]
Yes, it's the longest 45 minutes of the day sometimes. You're drawing just in 15 minutes or you're getting one at 0, 5, 10 and 15 minutes?

[Dr. David Goldenberg]
No, I'm sorry, I should have been clearer. Yes, so the anesthesiologist draws it at the beginning of surgery. That's their baseline then 15 minutes afterwards. I have them draw when surgery starts, they take it from the foot, the patients wake up and ask why they have a needle hole in their foot. That's where we do it out of 15 minutes after excision of whatever it is, I'm excising.

(6) Locating Tricky Parathyroid Glands

[Dr. Dipan Desai]
Okay. Obviously sometimes these cases can be tricky where you go in thinking you have a single localized adenoma, or you start doing your four gland exploration and one of the parathyroid didn't read your wonderful textbook and is hiding. Can you talk us through some of the steps and places you go looking for a parathyroid that's not where it's supposed to be?

[Dr. David Goldenberg]
Sure. Someone once told me if it was easy, it wouldn't be fun. As you well know the pan-parathyroid surgery can be incredibly quick and easy and simple. There are times it can be very frustrating because where is it? It is paramount that the parathyroid surgeon understands the embryology of the parathyroid glands because that's the key to where the missing gland is if something is missing. I think that's what you're asking, correct?

[Dr. Dipan Desai]
Yes.

[Dr. David Goldenberg]
The lower parathyroids have a longer descent and therefore they're more apt to get lost. That's just the way it is in medicine or an anatomy embryology and the most common place for a lost lower parathyroid is in the mediastinum together with the thymus and other places that they can be, would be, in the carotid sheath and even inside the thyroid gland. The upper parathyroid, and I have seen those get lost. They also are in the carotid sheath. They're usually retropharyngeal or retroesophageal.

I'm not talking about case reports where they're in the submandibular gland or some really really strange place. Depending which parathyroid is missing, if you're looking for them and every patient is, should be consented for, even if it's a focused parathyroidectomy, every patient is consented for a parathyroid exploration and possible hemithyroidectomy, which is the last place you look, if you are missing a gland and you've looked in the mediastinum, you've dissected the mediastinum you've looked in the carotid sheaths and you're still missing a gland, then we've all seen intra thyroidal parathyroid glands. Most of the intra thyroidal parathyroid glands are in the capsule. They're not really deep in the substance and sometimes you can actually see it, but sometimes it's actually in the substance of the gland.

[Dr. Ashley Agan]
How common is it for it to be in the gland?

[Dr. David Goldenberg]
It's not common. More often you'll see it inside the capsule, but outside the gland like inside the thyroid capsule, but not really in the substance but that also is not all that common.

[Dr. Ashley Agan]
Yes. If you're not finding it you should not be too quick to say, oh, it's probably in the thyroid.

[Dr. David Goldenberg]
No, you have to. If it's a lower, you really do need to dissect the upper mediastinum like you would a central compartment lymph node dissection, and you pull up the thymus like a magician pulling scarves out of a hat and that's the most common place that you would find it. I have seen them in the sheath and I've seen uppers behind the esophagus as well. It happens, the more you do, the more often you're going to see these things and I guess those are the ones that take a little bit more clinical acumen.

[Dr. Dipan Desai]
When you're dissecting out either the central neck compartment or looking in your thyroid gland, are you relying on your pathologist or is it still a visual examination?

[Dr. David Goldenberg]
Oh, I will absolutely rely on my pathologist at that point in time. That's a perfect example of when you need the help of the pathologist. Now Dipan, I'm sure you know this because you do this all the time. When you see a parathyroid adenoma, there it is, it looks like a little piece of liver. It has a certain look to it. Here we go again with food, but sometimes it's hard to tell. For example, Hashimoto's thyroiditis is incredibly common.

Hashimoto's thyroiditis comes with a lot of these little round lymph nodes and sometimes it can be confusing. It's not out of the realm of possibility that your patient has Hashimoto's thyroiditis and they have hyperparathyroidism. Then sometimes you are looking at a whole bunch of little grapes. and you have to make sure that this is in fact, the parathyroid. You just didn't remove an inflamed lymph node. Yes, we definitely would rely on the pathologist if I'm not sure or if I want to differentiate thyroid from parathyroid. Absolutely.

(7) Parathyroid Carcinoma

[Dr. Dipan Desai]
Obviously, the worst case scenario is, as you mentioned, super rare but a parathyroid carcinoma. I know that diagnosis can be very difficult. Have you ever encountered that, and what are some of the signs intraoperatively that you might be dealing with something that's not a normal parathyroid adenoma?

[Dr. David Goldenberg]
Well. Before we go intra-operatively, preoperatively patients who have parathyroid carcinoma are more apt to come with incredibly abnormal calcium and parathyroid hormone. Their calcium can be dangerously high, and that's the first thing that can bring them to medical attention. They've been in the emergency room, they've gotten their fluids and no one knows why. Oftentimes parathyroid hormone will be incredibly high. If primary hyperparathyroidism you'll have parathyroid hormone in the hundreds, parathyroid carcinoma, you could have in the 1000s. They will often come with a mass in the neck.

While a patient with primary hyperparathyroidism their physical exam is completely unremarkable unless you want to count aches and pains, and kidney stones. They may have a lump in the neck, a mass in the neck, a fixed thyroid, something that doesn't seem right. Those patients should be treated like any other patient with an aggressive cancer, more like a squam than with thyroid cancer in my mind, because parathyroid carcinoma, as rare as it is, can be pretty nasty. Those patients will probably lose at least half the thyroid, perhaps a neck dissection depending on what is found on preoperative imaging and what you find intraoperatively. Obviously, like any other oncological case, anything that it is stuck to, needs to go. Unfortunately a rare entity.

[Dr. Ashley Agan]:
Those patients probably get a preoperative FNA since they have a mass that's big enough to biopsy.

[Dr. David Goldenberg]
They do, or they can. I've only seen this in a handful of cases in my career. That's how uncommon it really is. Most of the patients-- trying to think back, because it really is not that common. I guess some of them were originally thought to have thyroid cancer because that's what it looked like on the imaging. F and A directed correctly with washouts could probably do the diagnosis for you.

(8) Post Operative Care

[Dr. Dipan Desai]
Then once you've completed your surgery, and you've successfully found the parathyroids, and your labs have corrected, postoperatively you mentioned your admitting versus discharge patterns. Do you give them any medication afterward or any calcium taper? Anything special you do in the postoperative period?

[Dr. David Goldenberg]
We do typically give them a small calcium taper. I wish I could tell you that I've been successful in being able to differentiate those who are going to develop hungry bone syndrome or something like that. It happens. We just don't want the patients to go home and start to feel sick. They are given calcium taper. I forgot to mention. I think where I have mentioned in the beginning, hopefully, their vitamin D was optimized before surgery, we try to do that. They go home, they're usually happy and we do see their calcium pretty soon afterwards. Most of them are just great. They're very happy, they feel great.

It's a very gratifying surgery as a surgeon to be perfectly honest. The array of symptoms abates very quickly. As a matter of fact, we published a study in laryngoscopes, I believe in '18, or '19, where we looked at cognitive symptoms, depression scores before and after surgery. We found that within a week of surgery, the patients were like new people. Their scores came up, their depression was down. Right now we're actually doing a study looking at using actigraphy to look at patients' sleep habits before and after surgery, because most of these patients do very, very well, and they feel like new people very soon after surgery.

[Dr. Dipan Desai]
Yes. I agree with you completely. It's a super gratifying surgery, and oftentimes, just as you mentioned earlier, in the podcast, they've had symptoms that have been either misdiagnosed or neglected as just part of aging for a long time and, to do something where they pretty much instantly feel better is pretty awesome.

[Dr. David Goldenberg]
If I could give a title to parathyroid surgery, the title would be, ''You've given me my old wife back'' because I've heard so many husbands say that after parathyroid surgery.

[Dr. Ashley Agan]
Wow.

[Dr. Dipan Desai]
You briefly mentioned hungry bone syndrome. Can you talk a little bit about what that is and who is prone to getting it?

[Dr. David Goldenberg]
Sometimes what happens is, the serum calcium decreases relatively quickly because of re-calcification of the bones. Remember, the bones got leached of their calcium, and now they want it back. It's called hungry bone syndrome. It typically happens within the first days or weeks after surgery. It's typically a sequela of more symptomatic hypercalcemia. People feel yucky. They have muscle cramps, and they have a clinical picture of tetany, just like they would for any other hypocalcemia. That's one of the reasons that we support patients with calcium orally. If this happens, then they come in, and they usually get intravenous calcium infusions.

It can be relatively dangerous if it's not treated at all because it is a form of hypocalcemia. It's not common, but it's something that we do see, and the patients typically need to be made aware of the signs of hypocalcemia, so that they could recognize it once they go home. That's why it's important to educate your patients. In my practice, we're the only academic show in town to have patients come from far and wide across the Commonwealth of Pennsylvania, and certainly, you don't want someone going who lives four hours away, they have the signs and symptoms and they don't really know what's going on.

[Dr. Ashley Agan]
Postoperatively, are you checking calcium levels routinely?

[Dr. David Goldenberg]
I think they get a calcium check before discharge typically, and they go home on calcium. I wish I could tell you exactly what the protocol is. I don't know.

[Dr. Ashley Agan]
Do you just use TUMS like calcium carbonate?

[Dr. David Goldenberg]
Yes, typically, we do use calcium carbonate.

[Dr. Ashley Agan]
Cool.

[Dr. Dipan Desai]
Obviously, a lot has been made in regard to innovations around parathyroid surgery with autofluorescence of parathyroid glands during thyroid surgery. Can you speak to if that's useful at all during parathyroid surgery, you're trying to find a hard parathyroid gland?

[Dr. David Goldenberg]
I can't speak from experience because I don't know, I don't use it. In theory, the autofluorescence of parathyroids that they fluoresce has been used, so you don't accidentally avulse. You can see them so you don't avulse them during thyroid surgery. People have said, ''Okay. Can we use that same technology to find a hard to find parathyroid?' Again, I haven't used it, but I've been around long enough to know or to remember when they did the same thing with methylene blue. There have been multiple attempts to try and dye the parathyroid in order to find it. I guess anything that helps is wonderful. Typically, the surgical principles are enough to find the offending parathyroid in my mind, but again, I've not done it, so I can't speak to it.

[Dr. Dipan Desai]
No. Sure. Thanks for letting me know.

(9) Head and Neck Endocrine Surgery: A Comprehensive Textbook, Surgical and Video Atlas by Dr. David Goldenberg

[Dr. Ashley Agan]
Rounding out this conversation, what I definitely want to do is give Dr. Goldenberg the opportunity to spotlight his book, Head & Neck Endocrine Surgery so that we can let our listeners know about that resource to check out. Can you tell our listeners a little bit about that?
[Dr. David Goldenberg]
I published a book in I believe '21, called Head & Neck Endocrine Surgery: A Comprehensive Textbook, Surgical, and Video Atlas. I have contributors who are the who's who of thyroid and parathyroid surgery, including your mentors there at Hopkins, both Dr. Russell and Dr. Tufano, who's now in Sarasota, as well as other people whose names, those of us who do this know their names. It covers all aspects of medical and surgical management of both thyroid and parathyroid disease.

When I wrote this book, first of all, I included novel or so called novel topics such as radiofrequency ablation, risk stratification, remote access, surgical techniques, molecular testing, all the things that those of us who are doing this now use routinely, but may not be familiar to those who don't do it as often and in as five sections on the thyroid gland, basic science, historical, ethical, medicolegal concerns, all those things.

Then two sections on parathyroid disease and parathyroid surgery. What makes it unique is it's written for the modern learner or for the millennial, it has a lot of illustrations. Each chapter comes with a high-yield case report to underscore what the issue is. It has key points and pearls in every chapter, called points to ponder where the reader is asked a question, to try and underscore that they understood what they just read. It has annotated bibliographies whereby references to the most-- the landmark studies are written out with a little abstract. Of course, there's 30 or so videos for surgery. It was published by THIEME, T-H-I-E-M-E, which is a medical publishing house out of Stuttgart, Germany.

[Dr. Ashley Agan]
Listeners could probably find it on Amazon?

[Dr. David Goldenberg]
Oh, yes. You can do it on Amazon, absolutely.

[Dr. Ashley Agan]
Or where you usually get resource wherever you find your medical textbooks probably,

[Dr. David Goldenberg]
Correct. Thank you very much for that.

[Dr. Ashley Agan]
Your medical textbook store of choice.
[Dr. David Goldenberg]
Right.

[Dr. Ashley Agan]
Awesome. Thanks so much for taking the time today. That was definitely a great review for me as I haven't been doing these over the last several years and Dipan thank you so much for joining. It was great having your point of view in being able to reconnect with you, so thanks for coming on the show today.

[Dr. David Goldenberg]
Thank you both and please give my best regards to my friends at Hopkins.

[Dr. Dipan Desai]
Definitely will do. Thanks, Dr. Goldenberg.

Podcast Contributors

Dr. David Goldenberg

Dr. David Goldenberg is a professor and the chair of the department of otolaryngology - head and neck surgery at Penn State in Hershey, Pennsylvania.

Dr. Dipan Desai

Dr. Dipan Desai is a practicing otolaryngologst and head and neck surgeon with ENT Associates in St. Petersburg, Florida.

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, January 17). Ep. 85 – Surgical Management of Parathyroid Disease [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.