Hyperparathyroidism (core) | May present with fatigue, headaches, anxiety/depression, bone/muscle pain, kidney stones Oftentimes, hypercalcemia is incidentally found on routine labs History of MEN syndrome (I, IIa)? Perform neck exam | Serum calcium, PTH level, BMP Vitamin D level—in patients with low vitamin D, start patient in vitamin D supplementation and then recheck PTH and calcium in several months (low vitamin D can artificially elevate PTH) 24-h urine calcium to rule out familial hypocalciuric hypercalcemia Renal U/S to look for nephrolithiasis DEXA bone scan Consider genetic counseling if genetic syndrome suspected In cases of primary hyperparathyroidism 80% is due to single gland disease (adenoma), 15-20% due to multigland disease, <1% due to parathyroid malignancy Localization studies—if planning to operate, obtain one or more of these studies to localize the abnormal gland: - U/S—usually the initial localization test, obtain others if not diagnostic - Sestamibi scan - 4D CT - PET-CT - MRI - Selective venous sampling | Indications for parathyroidectomy: - Symptomatic - Age <50 yo - Serum Ca >1 mg/dL above upper limit of normal - Renal involvement—nephrolithiasis, nephrocalcinosis, GFR <60 mL/min - Hypercalciuria—urine calcium >400 mg/24 h - Osteoporosis (T-score ≤ -2.5 or vertebral compression fracture) - Poor follow-up Single adenoma → parathyroidectomy Parathyroid hyperplasia → 3.5 gland excision Treatment of hypercalcemic crisis: - Normal saline bolus until rehydrated - Lasix, calcitonin, and/or bisphosphonates, as needed | Parathyroidectomy (core): - Ideally, abnormal gland has been localized with preoperative imaging so that focused parathyroidectomy can be performed; however, if unable to localize then need to do 4 gland exploration - Check preoperative PTH - +/− Recurrent laryngeal nerve (RLN) monitoring during case - Make collar incision, create sub-platysma skin flaps, split strap muscles and dissect them off the thyroid - Retract thyroid gland medially, identify and ligate middle thyroid vein - Identify and preserve recurrent laryngeal nerves |