This 40 year-old woman presented with hyperparathyroidism and extremely high PTH (1200 pg/ml).
A sestamibi scan showed a large right inferior parathyroid adenoma and an area of increased uptake in the left submandibular gland region.
A right inferior parathyroidectomy was performed and a large adenoma removed. The PTH and calcium levels did not drop until the left submandibular mass was removed. This mass was an undescended left inferior parathyroid adenoma.
Abstract: From July, 1982 to April, 1989, a total of 145 patients with persistent or recurrent primary hyperparathyroidism (HPT) were explored; 105 patients had an adenoma as the cause of HPT, and in 9 patients (9%), the abnormal gland was located at or superior to the carotid bifurcation (undescended parathyroid gland). These 9 patients had 14 prior explorations for HPT including 4 median sternotomies and 5 thyroidectomies.
Each of the 9 patients was symptomatic of HPT, including bone disease in 8 of 9 patients and renal stones in 4 of 9 patients. Seven patients had an undescended parathyroid adenoma correctly localized preoperatively by ultrasound (n=5), angiography (n=5), venous sampling (n=1), or computed tomography scan (n=4). These 7 patients with accurate preoperative localization were explored by an incision anterior to the sternocleidomastoid muscle high in the neck that avoided the previous operative field and allowed rapid resection of the parathyroid adenoma. In the 2 patients who did not have accurate preoperative localization, the undescended adenoma was found after long tedious exploration including median sternotomy in 1 patient. Each patient (n=9) who had an undescended parathyroid adenoma removed was cured of hypercalcemia, and 5 patients required postoperative 1,25-dihydroxy vitamin D3 for hypocalcemia.
We conclude that undescended parathyroid adenomas comprise a significant proportion (9%) of adenomas during reoperations for persistent HPT. The majority of these glands (78%) can be accurately imaged preoperatively and, when imaged, can be easily resected by a rapid, direct, surgical approach.
Right inferior parathyroidectomy.
Excision of undescended left inferior parathyroid adenoma from the left submandibular area.
Sestamibi parathyroid scan at 3 hours, showing a "hot" spot in the right inferior parathyroid region and a much brighter signal in the left submandibular area.