Hi Doc. I'm just helping my wife research surgeons the surgical technique(s) they use in the case of hyperparathyroidism. I'm having a hard time visualizing operating through a 2-3 cm incision and trying to locate tiny glands that may, in some cases, reside low in the chest or as high as the salivary glands. I'm curious if you use a high resolution scan to first find the exact locations of all 4 parathyroids. Thanks.
.png)
Hi! Great question. Patients are often amazed that we can see all four parathyroid glands through such a tiny incision. The secret is that most parathyroid glands are really not that far apart. They are usually close to the center of the neck, and located within a couple inches of each other.
Their closeness does not mean that they are easy to find! Inexperienced surgeons are frequently not able to find all four glands, because they are not just sitting out there like in an anatomy drawing. If you haven’t done thousands of operations, the glands can be very difficult to find, even if you are within millimeters of them. Basically: the glands are difficult to find, but not because they are far apart. If you are experienced at finding them, you can do it through a 2.5 cm (1 inch) incision in most people (it will need to be larger if you have a larger neck).
You bring up another point, though, which is that some parathyroid glands are in “ectopic” locations, meaning they aren’t in the standard spots in the neck. These include glands that are very high up in the neck near the jaw, and glands that are far down in the chest. And you are correct that you may not be able to reach these through the standard incision. This is exactly why I get a high-resolution sestamibi scan before surgery. I’m not trying to find the parathyroid tumor. I am just using the scan to rule out those ectopic location tumors. When a tumor is in one of those weird locations, there typically is not anything to hide it. When parathyroid glands are in the normal locations, they can easily be hidden by the thyroid, which is the most common reason why scans are negative. I don’t really care if the scan can show me a tumor in a normal location, since that is where I’m going to be looking anyway (I look at all four parathyroid glands). I only care if the tumor is in a weird place that will change the operation somehow (I may need a different incision than the standard one).
We don’t have any scans that can reliably find all four parathyroid glands. Some 4DCT scans will claim to locate all four, but these are very often inaccurate (4DCTs too commonly give both false positives and false negatives for parathyroid tumors, which confuse and mislead inexperienced surgeons, so in general I don’t recommend them as first-line imaging). Again, though, it doesn’t matter too much to me if it can find a normal gland in a normal location, since I’m going to see that when I operate anyway. I just need to know if there is a tumor in a weird location, because that will change how I do the operation.
