Persistant Hyperparathyroidism

Answer: b, c



Persistent hyperparathyroidism occurs in less than 5% of patients after neck exploration for primary hyperparathyroidism by an experienced surgeon. Most commonly, it is the result of a single diseased gland still remaining in the neck or in the mediastinum. Recurrent disease develops after an interval of normocalcemia and may be the result of regrowth of diseased tissue, implantation from a tumor broken at the initial procedure, or even recurrent parathyroid carcinoma. Documentation of a correct initial diagnosis and review of the original operative and pathology reports are essential. It is generally agreed that localization studies do have a place in the management of recurrent disease. Noninvasive methods are employed first, and if these are unsuccessful in identifying the diseased gland, selective angiography and venous sampling for PTH are employed. Selective angiography appears to be the most accurate technique, successfully localizing 50% to 80% of parathyroid glands that cannot be detected by any other modality.

Surgical reexploration can be difficult. Generally the neck is explored first after which the mediastinum is examined if this is unproductive. Surgical reexploration is successful in experienced hands in 60% to 80% of cases. There is, however, an increased incidence of complications. Unilateral recurrent nerve injury occurs in 5% to 10% of patients and permanent hypoparathyroidism occurs in 10% to 20% of patients postoperatively.

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