Localization of abnormal parathyroid tissue with use of technetium-99m-sestamibi.

OBJECTIVE: To evaluate the efficacy of "double-phase" technetium-99m-sestamibi scanning in the localization of abnormal parathyroid tissue in patients with hyperparathyroidism. METHODS: We present a prospective review of patients with hyperparathyroidism seen at a university teaching hospital between June 1994 and May 1997. Twenty-four patients entered into the study underwent preoperative localization with double-phase technetium-99m-sestamibi. The nuclear medicine results were compared with the operative findings. RESULTS: The Tc-99m-sestamibi scan correctly identified the location of single parathyroid adenomas in 22 patients (100%). Of the other two patients, both with diffuse parathyroid hyperplasia, one had a negative sestamibi scan and one had only the two inferior parathyroid glands localized on the sestamibi scan. One patient with recurrent hypercalcemia, who previously underwent total parathyroidectomy and parathyroid autotransplantation into the left forearm, had activity localized to that forearm but not to the neck. Subsequently, hyperplastic parathyroid tissue was successfully removed from the transplantation site. Another patient, who had previously undergone two unsuccessful surgical explorations prompted by hyperparathyroidism, had sestamibi localization of an adenoma inferior and medial to the right submandibular gland. The third surgical exploration disclosed a large adenoma medial to the carotid artery, just below the angle of the jaw. In two elderly, debilitated women with positive scans, adenomas were removed with use of local anesthesia. Of 22 patients in whom long-term follow-up was available, 21 remained normocalcemic for a mean period of 11.4 +/- 1.7 months postoperatively. One patient in whom hyperplastic parathyroid tissue had been removed from the left forearm had recurrence of hypercalcemia 1 year after operation. CONCLUSION: Technetium-99m-sestamibi scanning is a reliable method for identifying parathyroid adenomas but not as helpful in localizing hyperplastic parathyroid glands. The precise localization of an adenoma simplifies surgical exploration and in selected patients may allow excision of the adenoma under local anesthesia. Tc-99msestamibi scanning has become the preferred method for noninvasive localization of abnormal parathyroid glands.

CO2 laser blepharoplasty. A comparison with cold-steel surgery.

This study compares and contrasts the use of the CO2 laser with the conventional cold-steel scalpel and electrocautery in cosmetic blepharoplasty. Ten patients underwent bilateral, upper, and lower eyelid cosmetic blepharoplasty using the CO2 laser as the exclusive cutting and cauterizing instrument for one eye, and the cold-steel scalpel and electrocautery as the exclusive cutting instrument and cauterizing tool for the remaining eye. This comparison evaluated administrative factors, procedural ease, and long- and short-term results. The benefits of using the CO2 laser rather than the cold-steel scalpel in blepharoplasty are reduced operative time, less bleeding, superior intraoperative visibility, less bruising and swelling, no pain or discomfort, and a shorter recuperation period. There were no complications with either the scalpel or the laser. Using the laser with standard safety protocols presents no greater risk to the patients undergoing blepharoplasty than does using the cold steel scalpel with an electrocautery device. The disadvantages of using the laser compared with the steel scalpel include the cost of purchasing and maintaining the laser equipment, the need for additional and extensive laser training for surgeons and assistants, and the need for two assistants rather than the one needed for scalpel surgery.

Clinical evaluation of pituitary adenomas.

Improvements in both diagnostic methods and surgical and medical treatment modalities for pituitary disease have been a major advance in endocrinology. Future refinements in visualization techniques and dynamic testing of pituitary function are to be expected and will further add to understanding of this complex spectrum of diseases.

How thyroid disease presents in the elderly.

Some of the symptoms and signs of hypothyroidism and hyperthyroidism in elderly patients may be mistakenly attributed to "old age." Weight loss, muscle weakness, tremor, angina, congestive heart failure--all signs of hyperthyroidism--are also concomitants of aging. Fatigue, sluggishness, withdrawal behavior, senile atrophic skin changes--all signs of hypothroidism--are also a part of the normal aging process. Although screening elderly people for thyroid disease is economically unsound, the physician should maintain a high index of suspicion of its presence. Laboratory tests must be interpreted with extra care. Values of 131I uptake, serum T4 and T3, thyroid-stimulating hormone, and thyrotropin-releasing hormone are all helpful in diagnosis. Thyroid disease is easily treated in elderly patients, and results often are dramatic. Propranolol is effective in thyrotoxic patients when symptoms require prompt relief. The definitive treatment, however, is 131I; antithyroid drugs are difficult to manage. Hypothyroidism is easily treated with T4.

Hirsutism.

Many women have some facial hair, and most patients who seek advice will be at the far end of the normal distribution curve for hair. In a second group there is a slight excessive production of androgens with associated hirsutism, either idiopathic or associated with polycystic ovarian disease. An extremely small fraction of patients will have serious disorders of the adrenals or ovaries and significant elevations in androgen levels.