Parathyroidectomy via bilateral cervical exploration: a retrospective review of 866 cases.

INTRODUCTION: Parathyroidectomy via cervical exploration is an effective primary-modality treatment for hyperparathyroidism, with cure rates of greater than 95%. We retrospectively reviewed 866 consecutive parathyroidectomies performed by a single surgeon between 1960 and 1997. We attempted to describe the polymorphic variation in multiglandular disease, the anatomic locations of pathologic glands, and the operative strategy and techniques which we believed were important to minimizing morbidity and maximizing curative success. METHODS: The cases of 329 males and 537 females (age, 1-88 years) were reviewed. There were 766 operations performed: primary hyperparathyroidism (713), tertiary hyperparathyroidism (100), reoperations (53). The strategy for primary exploration includes a bilateral neck exploration, early recurrent laryngeal nerve skeletonization, and identification of at least four glands. RESULTS: Normocalcemia was achieved in 98.2% of cases after initial cervical exploration. Persistent hypercalcemia occurred in 7 patients (<1%). Nine patients (1%) suffered persistent postoperative hypocalcemia. Unilateral recurrent laryngeal nerve injury occurred in two patients (<1%). Other perioperative complications included: reoperation for hematoma, repaired carotid artery injury, unexplained dysphagia, pneumothorax, deep venous thrombosis, and aspiration pneumonia. There were two mortalities (<1%) attributable to severe, comorbid disease. Ectopic glands were found in 120 cases. The frequency of glands at these sites were as follows: mediastinal (4.9%), intrathymic (8.4%), intrathyroid (6.7%), and retroesophageal/retrotracheal (3.5%). Thyroid resections provided diagnosis of concomitant thyroid carcinoma in 8.0% of resected patients. The pathology of patients with primary hyperparathyroidism (PHPT) consisted of single adenomas (77.2%), hyperplasia (21.0%), normal glands (1%), double adenomas (<1%), and parathyroid carcinoma (<1%). The distribution of adenomas was as follows: left upper, 25.3%; left lower, 27.3%; right upper, 26.8%; right lower, 20.6%. Hyperplastic glands were found in ectopic positions as follows: intrathymic (7.5%), intrathyroid (11.3%), mediastinal (2.5%), and retroesophageal/retrotracheal (0%). The average volume difference between the largest and smallest hyperplastic gland of each case was 1.80 + 4.40 cm3. Reoperations were performed upon 53 referred patients and 7 patients after failed exploration. Normocalcemia was attained in 98.3% of cases. Glandular pathology was identified in the previous operative field in 52 patients (86.7%). Adenomas were identified in 56.0% (n = 23) and hyperplasia in 39.0% (n = 16). CONCLUSIONS: In our series, we were able to attain normocalcemia in 98.2% of cases after initial cervical exploration. We believe that identification of four glands, an exhaustive search of ectopic sites, bilateral exploration, and liberal use of biopsy and intraoperative frozen section were essential to curative success. The pathologist should identify parathyroid tissue in the specimen and differentiate the "abnormal" from "normal" gland. Morphologic criteria alone cannot be used because of polymorphic variation in hyperplasia in which pathologic glands may appear normal. Early identification of the recurrent laryngeal nerve allows for a safer neck exploration by alerting the surgeon to the location and course of the nerve. A bilateral approach does not contribute increased morbidity from recurrent laryngeal nerve injury.

Face and neck neurogenic neoplasms.

Surgeons should be aware that any mass in the region of the cranial nerves, brachial plexus, cervical sympathetic plexus, or a major peripheral nerve can be of neurogenic origin. Solitary neurogenic tumors of the head and neck can simulate metastatic masses or congenital lesions. If they are resected unrecognized and/or without regard to their nerve origin, major and permanent nerve defects can unnecessarily occur. Thirty-two patients, 16 males and 16 females, ranging in age from 5 to 69 years, had 33 extracranial solitary neurogenic neoplasms resected. The nerves involved were the cervical sympathetic plexus in 7 patients, branchial plexus in 6, spinal accessory nerve in 5, vagus nerve in 4, hypoglossal nerve in 3, facial nerve in 2, and 6 other nerves in 1 patient each. The technique is to dissect out the neurilemoma without destroying the nerve sheath or nerve trunk. Despite careful dissection, the four patients with masses of the vagus nerve had permanent ipsilateral cord paralysis.

Anastamoses and bifurcations of the recurrent laryngeal nerve--report of 1177 nerves visualized.

One thousand seventy-seven recurrent laryngeal nerves were observed in 719 patients. Seven hundred forty-seven nerves bifurcated or trifurcated over 0.5 cm inferior to the cricoid cartilage (63%). Of these, 170 patients had bilateral nerve bifurcations. Thirty-nine per cent of the patients had bilateral bifurcations when one side bifurcated. Eleven patients had direct laryngeal nerves, two of which bifurcated. Five of these 11 patients also had a recurrent and direct laryngeal nerve. Seven patients had recurrent laryngeal nerves, all on the right side, receiving branches directly from the vagus nerve 6-14 cm from the cricoid. Damage to any filaments to or from the recurrent laryngeal nerve can cause vocal cord paralysis. Damage to branches to the esophagus from the recurrent laryngeal nerve can cause dysphagia.

Incidental preclinical hyperparathyroidism identified during thyroid operations.

The entity of preclinical hyperparathyroidism has never been clearly investigated. The authors believe that the incidence of pathologic abnormalities of the parathyroid glands before the development of any symptoms or hypercalcemia (serum calcium > 12.0 mg/dl) is more frequent than has been reported. Over a 14-year period, parathyroid glands were examined during thyroid operations in over 800 patients. Serum calcium and phosphorous levels were measured in all patients preoperatively. Thirty-six patients had additional parathyroid operations for a preclinical form of hyperparathyroidism, defined by abnormal appearing parathyroid glands at the time of thyroid surgery. None of the 36 patients had symptoms of hyperparathyroidism preoperatively. Nine patients had borderline hypercalcemia (serum calcium 10.6 to 12.0 mg/dl), and the remainder were considered normocalcemic. The average age was 53 (range 21 to 75) with a male to female ratio of 1:3. Nine of the 36 patients had thyroid cancer. There were eight patients with parathyroid adenoma and 28 patients with parathyroid hyperplasia. Of 13 patients who had a history of neck irradiation, five had parathyroid adenoma and eight had parathyroid hyperplasia. Only two patients with parathyroid hyperplasia remain on calcium medication. Since preoperative normocalcemia does not preclude the presence of parathyroid pathology, the authors urge careful identification and examination of the parathyroid glands during thyroid operations. It adds little time to the procedure. Excision of parathyroid disease along with the thyroid gland can be performed safely and prevents the need for further operation with its associated morbidity.

Fifty-three reoperations for hyperparathyroidism.

Fifty-three patients, 35 with persistent and 7 with recurrent hyperparathyroidism, had parathyroid surgery. There were 11 patients who had prior thyroid surgery before being identified as having hyperparathyroidism. Forty patients had parathyroid adenomas and 13 (8 dialysis patients) had parathyroid hyperplasia. Thallium-210-iodine 123 subtraction scanning proved to be the most accurate in localizing parathyroid adenomas (60 percent) but not parathyroid hyperplasia. Resection of 3 3/4 parathyroid glands in primary parathyroid hyperplasia and total parathyroidectomy with parathyroid autotransplantation in tertiary parathyroid hyperplasia are the treatments of choice and would have prevented reoperation in this group. Careful neck exploration, resection of the thymus, and even thyroidectomy would probably have led to the correct location of the missed parathyroid adenomas. Mediastinotomy should not be performed at initial surgery. A careful history and preoperative calcium and phosphorus determinations in all thyroid surgery patients will reveal occult hyperparathyroidism. Twenty-one such patients were identified in our overall parathyroid series.

Thyroglossal duct cysts. A thirty year experience with emphasis on occurrence in older patients.

A total of 79 patients (39 female and 40 male) underwent the Sistruck procedure for thyroglossal duct cysts. Twenty-eight percent of the patients were over 50 years of age and 10 percent were over 60. The age range was 16 months to 82 years. Three patients had thyroidectomies, two of which were for carcinoma, along with resection of a thyroglossal duct cyst. Two patients, one diagnosed preoperatively by needle biopsy, had papillary carcinoma in thyroid tissue of the cyst wall. The length of time from cyst discovery to surgery was the same for patients over 10 years of age. We suggest needle biopsy of all neck masses and also elective operation in a patient of any age, once a diagnosis of thyroglossal duct cysts is made. The Sistrunk procedure is the operation of choice.

The clinical significance of the various anastomotic branches of the facial nerve. Report of 100 patients.

During parotid dissection, we have found significant variations in the facial nerve branchings that have not been previously reported. One hundred patients, 48 males and 52 females, had their facial nerve photographed and/or diagrammed during parotid surgery. Ninety-nine patients had facial nerve configurations that could be divided into five main types. One nerve could not be classified into any of these types because of a bizarre configuration. Twenty-four percent of patients had a straight branching pattern (type I); 14% of patients had a loop involving the zygomatic division (type II); 44% of patients had a loop involving the buccal division (type III); 14% of patients had a complex pattern with multiple interconnections (type IV); and 3% of patients had two main trunks, one major and one minor (type V). Familiarity with these common variations in facial nerve anatomy is an absolute necessity for the operating surgeon.

Extralaryngeal division of the recurrent laryngeal nerve. Report on 400 patients and the 721 nerves measured.

Seven hundred twenty-one recurrent laryngeal nerves were visualized in 400 patients having thyroid or parathyroid surgery. Four hundred twenty-one nerves (58 percent) bifurcated or trifurcated more than 0.5 cm from the cricoid cartilage. Ninety-seven patients had bilateral bifurcations, and 10 patients had trifurcations. Six patients had direct laryngeal nerves, all on the right side. One patient had a direct laryngeal and a recurrent laryngeal nerve simultaneously, and one patient had a bifurcated recurrent laryngeal nerve with an accessory vagus nerve joining it 13.5 cm from the cricoid cartilage. Damage to any of the filaments of the recurrent laryngeal nerve to the cricothyroid musculature or to or from a variant direct laryngeal nerve or variant vagus nerve connection can cause vocal cord paralysis. Damage to any branches of the recurrent laryngeal nerve to the esophagus can cause dysphagia. Therefore, if possible, all branches of the recurrent laryngeal nerve, no matter how small, should be preserved.

Needle aspiration of nonfunctioning parathyroid cysts.

Parathyroid cysts, appearing as thyroid masses, have been previously diagnosed at operation or by permanent histologic specimens. With the advent of ultrasound and fine-needle biopsies, these very rare cysts can now be diagnosed by needle aspiration. The pearly clear fluid of a parathyroid cyst contrasts with the sanguineous or even chocolate-brown fluid of a thyroid cyst. The high parathyroid hormone (PTH) level of the fluid confirms the diagnosis, and a blood calcium level determines its function or nonfunction in the patients. Of our seven nonfunctioning parathyroid cysts, the first three were diagnosed by operation and the other four by needle aspirations. The PTH determination ranged from 20,000 to 42,000 pg/mL. We suggest that needle aspiration, rather than operation, be the treatment of choice.

Salivary gland tumors and previous radiotherapy to the head or neck. Report of a clinical series.

To estimate what proportion of patients with newly diagnosed salivary gland tumors may have radiation-related disease, we interviewed all 275 patients in a surgical practice who had salivary gland resections during an 8 year period. Patients were asked about previous radiation treatment to the head and neck. Thirty-one patients (11 percent) had both an incident salivary gland tumor and a history of significant exposure. Four of these patients (13 percent) had multiple primary tumors of the salivary glands. The implications and generalizability of these findings have been discussed herein.

Parathyroidectomy. Review of 338 consecutive cases for histology, location, and reoperation.

Three hundred thirty-eight consecutive parathyroidectomies for hyperparathyroidism were performed over a 22 year period. There were 53 dialysis patients (31 male and 22 female), 285 patients (165 female and 120 male) with primary hyperparathyroidism, 55 patients (19 percent) with parathyroid hyperplasia, and 230 patients with 236 parathyroid adenomas. The location of the adenomas were right upper in 57, right lower in 59, left upper in 60, and left lower in 60. Forty-three patients of the last 194 operated on had histories of childhood head and neck irradiation (21.6 percent), 34 patients (79.6 percent) had associated thyroid disease, and there were 10 with thyroid carcinomas. In the 285 patients, 54 percent had thyroid disease, and 18 had thyroid carcinomas. Twenty-three patients required reoperation for persistent or recurrent hypercalcemia, and 19 neck reexplorations and 6 mediastinotomies were performed. The identification and biopsy as indicated of all four parathyroid glands at initial neck exploration would have prevented over 70 percent of reoperations.

Extralaryngeal divisions of the recurrent laryngeal nerve. Surgical and clinical significance.

Extralaryngeal branches of the recurrent laryngeal nerve have been noted in the literature, but frequently the researchers fail to indicate with accuracy the site of bifurcation. The current study was undertaken to designate the exact level of bifurcation of the recurrent laryngeal nerve, with more precise localization using a standard anatomic landmark. A prospective study based on 83 surgical patients was performed. The location of all nerves was measured using the inferior border of the cricoid cartilage as the anatomic landmark. A total of 153 recurrent laryngeal nerves were observed. Sixty-three (41.2 percent) bifurcated or trifurcated into extralaryngeal branches. Of these, there were four instances of trifurcations. The remaining 59 nerves bifurcated. Of these, 14 nerves bifurcated into equal-sized branches which went in an anterior or posterior direction. The remaining 45 nerve bifurcations indicated that 39 (86.7 percent) of the small branches went in a posterior direction, whereas only 6 (13.3 percent) of the large branches went in that direction. Surgical and clinical implications of this finding were discussed. Two instances of a "nonrecurrent" laryngeal nerve (that occurred on the right side) were also noted. The results of this study demonstrate conclusively that extralaryngeal branches of the recurrent laryngeal nerve are not an anatomic rarity. Therefore, thyroid surgery must include identification and preservation of the recurrent laryngeal nerve and all of its divisions.

Parathyroid autotransplantation in patients with parathyroid disease and total thyroidectomy. Indications in 117 cases.

Parathyroid autotransplantation is a known and increasingly utilized procedure. It is indicated in patients with primary parathyroid hyperplasia, in patients with primary hypercalcemia who have normal parathyroid tissue devascularized during surgery, in patients with secondary and tertiary parathyroid hyperplasia, and in patients with total thyroidectomy when normal parathyroid tissue is accidentally or unavoidably removed or completely devascularized. No normal viable parathyroid tissue should be autotransplanted. This procedure was performed in 13 dialysis patients, 27 primary hypercalcemic patients and 77 patients with thyroidectomy. The hypercalcemic patients had autotransplantations into muscle pockets in the volar surface of the forearm, while the thyroidectomy patients had autotransplantation into the sternocleidomastoid muscles. The application of parathyroid autotransplantation is a major technical and physiologic breakthrough in the field of thyroid and parathyroid surgery. It should greatly reduce the morbidity associated with permanent hypocalcemia in this type of extensive surgery.

Thyroid and associated polyglandular neoplasms in patients who received head and neck irradiation during childhood.

One hundred fifty-one patients with a history of childhood irradiation to the head, neck, and thorax had neck explorations (142 for "cold" thyroid nodules and 9 for hypercalcemia). Fifty-nine of the patients had thyroid carcinoma, and associated glandular tumors were found in 20 others. In addition, 6 female patients developed breast carcinoma; 4 of these women also had thyroid carcinoma. In this series, 48.6% of the patients irradiated for acne and 36.4% with tonsil and adenoid irradiation developed thyroid carcinoma, but only 10.5% with thymic irradiation did so. It is suggested that the workup on these patients include not only complete thyroid and parathyroid testing, but also a careful examination of all salivary glands, both major and minor. Women should have thorough breast examinations and should perhaps be followed as if they were in the potentially high-risk breast group. When thyroid surgery is performed, a total thyroidectomy is recommended.

The malignant "cold" nodule of the thyroid.

From 1958 to 1976, 910 patients with cold nodules of the thyroid underwent thyroid surgery (714 females, 196 males). Thyroid carcinoma was present in 202 patients (22.2 per cent) (149 females, 20.9 per cent; 53 males, 27 per cent). Rate of malignancy in an age group was greatest in patients older than seventy years (19 of 47 patients, 40.4 per cent) followed by patients twenty-one to thirty years of age (37 of 125 patients, 29.6 per cent); 90 per cent of all patients were from twenty-one to seventy years of age. Blacks had a lower rate of thyroid carcinoma than Caucasians. Data from the Cancer Surveillance Group also showed age-adjusted incidence rates in blacks in Los Angeles County to be lower than that of Caucasians.

Parotid area swelling caused by a prominent transverse process of atlas.

Among 1,500 parotid sialography examinations, the diagnosis of a parotid mass caused by a prominent transverse process of the atlas was made in 18 patients. The diagnosis was confirmed in one patient who insisted on surgical exploration. The remaining 17 patients required no surgical procedure. Many head and neck surgeons have unwittingly operated on such cases with frustrating results. Hopefully, roentgenographic findings will assist in the confirmation of the diagnosis and eliminate the need for such operations.

Unusual lesions of the parotid gland.

Ten unusual cases of parotid tumors are added to the literature from a series of 318 consecutive parotidectomies. These 10 cases are: 3 branchial cleft cysts; a lipoma; a lymphangioma; a hemangiopericytoma; a Boeck sarcoid; a metastasizing basal cell carcinoma; a lymphoma of the parotid; and a metastatic adenocarcinoma from the left breast to the right parotid. The lymphoma, Case 1, is also an example of some other cranial nerve taking over the function of the facial nerve when it is destroyed in early childhood. Though most tumors of the parotid gland are of the mixed type, many suprising findings are possible. The pathology report may be the first clue to a hidden systemic disease.