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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 44-47

Ectopic undescended left parathyroid adenoma: Diagnosed on ultrasound


1 Division of Radiology and Nuclear Medicine, Medanta - The Medicity, Gurugram, Haryana, India
2 Head and Neck Onco Surgery, Medanta - The Medicity, Gurugram, Haryana, India
3 Division of Endocrinology and Diabetes, Medanta - The Medicity, Gurugram, Haryana, India

Date of Web Publication27-Jul-2017

Correspondence Address:
Alka Ashmita Singhal
Division of Radiology and Nuclear Medicine, Medanta - The Medicity, Gurugram, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_6_17

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  Abstract 

We report here a case of left ectopic undescended parathyroid nodule located high in the neck, at the angle of jaw which was diagnosed primarily on high-resolution color Doppler ultrasound imaging at our institution, followed by Sestamibi and computed tomography-single photon emission computed tomography (CT-SPECT) and surgery. A 41-year-old female having endometrial hyperplasia and planned for TAH + BSO. Her routine preoperative investigations showed serum calcium to be 13.0 mg/dL. Serum parathyroid hormone (PTH) was 914.6 pg/mL and 25–OH Vitamin D 8.0 g/mL. Ultrasound neck with color Doppler localized an ectopic undescended left parathyroid adenoma located high in the neck just adjacent to the left submandibular gland. Sestamibi was suggestive of the left ectopic undescended parathyroid adenoma (below the pole of the left submandibular gland), confirmed further on CT-SPECT. The patient was operated and a 30 mm × 23 mm × 10 mm sized parathyroid adenoma was removed and confirmed on histopathology. A dedicated high-resolution color Doppler ultrasound has a great potential to localize the parathyroid nodules in all cases of raised serum PTH and must be utilized in all cases along with other imaging modalities.

Keywords: Ectopic undescended, hyperparathyroidism, parathyroid adenoma, ultrasound neck with color Doppler


How to cite this article:
Singhal AA, Baijal SS, Sarin D, Arora SK, Mithal A, Khuchay SM. Ectopic undescended left parathyroid adenoma: Diagnosed on ultrasound. J Head Neck Physicians Surg 2017;5:44-7

How to cite this URL:
Singhal AA, Baijal SS, Sarin D, Arora SK, Mithal A, Khuchay SM. Ectopic undescended left parathyroid adenoma: Diagnosed on ultrasound. J Head Neck Physicians Surg [serial online] 2017 [cited 2021 Mar 2];5:44-7. Available from: https://www.jhnps.org/text.asp?2017/5/1/44/211731


  Introduction Top


Ectopic Undescended parathyroid adenomas are rare, representing 0.08% of all parathyroid adenomas.[1] They make up 7% of the underlying cause of failed cervical exploration in patients with persistent primary hyperparathyroidism.[2] They are often missed on preoperative imaging including sestamibi scan and ultrasound. We report here a case of the left ectopic undescended parathyroid nodule located high in the neck, at the angle of jaw which was diagnosed primarily on high-resolution color Doppler ultrasound imaging at our institution, followed by Sestamibi and computed tomography-single photon emission computed tomography (CT-SPECT) and surgery.[3]


  Case Report Top


Clinical history

A 41-year-old female patient having endometrial hyperplasia and planned for TAH + BSO.

Biochemical investigations

Her routine preoperative investigations showed serum calcium to be 13.0 mg/dL.

Serum parathyroid hormone (PTH) was 914.6 pg/mL and 25–OH Vitamin D 8.0 g/mL.

Further clinical evaluation

Revealed vague history of pains and fatigue. No other associated comorbidities.

Ultrasound neck with color Doppler: Findings

A well-defined ovoid hypoechoic (homogeneously hypoechoic) nodule measuring 34 mm × 15 mm × 12 mm, volume 3.0 cc was seen located just inferior and adjacent to the left submandibular gland in the upper neck suggestive of ectopic undescended left superior parathyroid nodule [e.g., [Figure 1],[Figure 2],[Figure 3]. On color Doppler, peripheral and eccentric vascularity is seen in the nodule [e.g., [Figure 4],[Figure 5], and [Video 1]].
Figure 1: Transverse scan of left upper neck showing the left submandibular gland and a hypoechoic nodule lateral to it

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Figure 2: Longitudinal scan of left upper neck showing the left submandibular gland and a hypoechoic nodule inferior to it

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Figure 3: Transverse scan of left upper neck showing the anatomical relationship of left submandibular gland, the ectopic parathyroid nodule, the carotid artery and internal jugular vein

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Figure 4: Full extent of the left ectopic undescended parathyroid gland showing slight inhomogeneity

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Figure 5: Color Doppler showing the characteristic arc of vascularity

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The nodule was located high in the upper neck just below the angle of jaw. It was just inferolateral and adjacent to the lower tip of the left submandibular gland and medial to the external carotid, internal carotid, and internal jugular vein. The depth level of this nodule was at the level of carotid vessels.

Both lobes of thyroid and isthmus appeared remarkable. Few subcentimeter inflammatory lymph nodes are seen in the bilateral cervical region (level II and III).

Radiological diagnosis of ectopic undescended left parathyroid adenoma located high in the neck just adjacent to the left submandibular gland was made.[4],[5]

Sestamibi findings

Increased uptake of technetium MIBI was seen below the lower aspect of the left submandibular gland which persisted in the delayed image at 2 h while thyroid gland shows normal washout. This is suggestive of left ectopic undescended parathyroid adenoma (below the pole of left submandibular gland). This was confirmed further on CT-SPECT images reformatted in coronal, axial, and transverse slices [Figure 6] and [Figure 7].
Figure 6: Computed tomography.single photon emission computed tomography multiplanar images of left ectopic undescended parathyroid at the level of left submandibular gland

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Figure 7: Axial fused computed tomography.single photon emission computed tomography images of left ectopic undescended parathyroid at the level of left submandibular gland

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Surgical findings

The patient was operated and a 30 mm × 23 mm × 10 mm sized parathyroid adenoma was removed [Figure 8],[Figure 9],[Figure 10].
Figure 8: The parathyroid nodule at surgery

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Figure 9: The gross surgical specimen of parathyroidnodule

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Figure 10: The parathyroid nodule and its size at surgery

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Frozen section report confirmed parathyroid adenoma. Reactive lymph nodes were seen.[6],[7]


  Discussion Top


Ectopic parathyroid glands occur in 5% of people, occasionally located high in the neck under the jaw (called a undescended parathyroid gland).[8],[9]

These are often overlooked by inexperienced radiologists and surgeons, especially when these parathyroid adenomas occur in uncommon or rare positions (ectopic parathyroids).

Conventionally, Sestamibi is considered as a gold standard to diagnose nodules in cases of hyperparathyroidism. Careful interpretation of scans is required in cases where ectopic lesion is to be localized, as often there is an overlap with the submandibular salivary gland uptake.[10]


  Conclusion Top


A dedicated high-resolution color Doppler ultrasound has a great potential to localize the parathyroid nodules in all cases of raised serum PTH and must be utilized in all cases along with other imaging modalities. Apart from detecting and localizing, ultrasound also gives precise anatomical landmarks for surgery and characterizes the nodule.[11] When utilized well, this state of art innovative technique of high-resolution color Doppler ultrasound diagnoses nodules in proven Sestamibi negative cases of hyperparathyroidism.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Roy M, Mazeh H, Chen H, Sippel RS. Incidence and localization of ectopic parathyroid adenomas in previously unexplored patients. World J Surg 2013;37:102-6.  Back to cited text no. 1
[PUBMED]    
2.
Fraker DL, Doppman JL, Shawker TH, Marx SJ, Spiegel AM, Norton JA. Undescended parathyroid adenoma: An important etiology for failed operations for primary hyperparathyroidism. World J Surg 1990;14:342-8.   Back to cited text no. 2
[PUBMED]    
3.
Chan TJ, Libutti SK, McCart JA, Chen C, Khan A, Skarulis MK, et al. Persistent primary hyperparathyroidism caused by adenomas identified in pharyngeal or adjacent structures. World J Surg 2003;27:675-9.  Back to cited text no. 3
[PUBMED]    
4.
Johnson NA, Carty SE, Tublin ME. Parathyroid imaging. Radiol Clin North Am 2011;49:489-509, vi.  Back to cited text no. 4
[PUBMED]    
5.
Okuda I, Nakajima Y, Miura D, Maruno H, Kohno T, Hirata K. Diagnostic localization of ectopic parathyroid lesions: Developmental consideration. Jpn J Radiol 2010;28:707-13.  Back to cited text no. 5
[PUBMED]    
6.
Mariette C, Pellissier L, Combemale F, Quievreux JL, Carnaille B, Proye C. Reoperation for persistent or recurrent primary hyperparathyroidism. Langenbecks Arch Surg 1998;383:174-9.  Back to cited text no. 6
[PUBMED]    
7.
Wang CA. Parathyroid re-exploration. A clinical and pathological study of 112 cases. Ann Surg 1977;186:140-5.  Back to cited text no. 7
[PUBMED]    
8.
Udekwu AO, Kaplan EL, Wu TC, Arganini M. Ectopic parathyroid adenoma of the lateral triangle of the neck: Report of two cases. Surgery 1987;101:114-8.  Back to cited text no. 8
[PUBMED]    
9.
Sadler TW. Langman's Medical Embryology. Baltimore, USA: Williams and Wilkins; 1995.  Back to cited text no. 9
    
10.
Herrera MF, Reza A, Graeff A, López-Graniel CM, López LH, Angeles A. Ectopic parathyroid adenoma in the posterior triangle of the neck. Rev Invest Clin 1993;45:589-91.  Back to cited text no. 10
    
11.
Stack BC Jr., Bodenner D, Bartel TB, Hinson AM. editors. Medical and Surgical Treatment of Parathyroid Diseases: An Evidence-Based. Switzerland; Springer: 2017.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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Abstract
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