Do I Really Need a Neck Ultrasound Prior to Parathyroid Surgery?

At Fort Lauderdale Endocrine Surgery (FTLES), we frequently are asked to perform surgery on patients with clearcut high serum calcium levels due to overactive parathyroids (hyperparathyroidism) who have not undergone adequate neck ultrasonography. There are several reasons for this sad state of affairs.

The first is that many physicians and patients have the mistaken impression that gamma camera sestamibi parathyroid scanning is the "gold standard" radiologic procedure for parathyroid localization. Unfortunately, gamma camera scanning frequently misses upper pole parathyroids (remember that there are typically 2 upper pole glands deep in the neck below the thyroid, one on the left and one on the right) and parathyroid glands that are close to pulsatile vascular structures. Also, sestamibi does not discriminate the multi-gland parathyroid disease that is present in up to 15% of patients. In fact, out-patient sestamibi scanning may miss up to 40% of "surgical" parathyroid enlargement and occasionally incorrectly identifies thyroid nodules or lymph nodes as "parathyroids."

The second reason for ultrasound mis-utilization is that parathyroid ultrasonography is becoming a "lost" art. As a result of declining reimbursement, most hospital and out-patient radiologic facilities have handed over thyroid and parathyroid ultrasound responsibilities to radiology technicians who are not formally trained in parathyroid localization. Sure, a radiology physician eventually reviews the pictures that the technician takes, but the radiologist is only as good as the technologist. At Fort Lauderdale Endocrine Surgery (FTLES), I personally perform ALL parathyroid ultrasonography without a "middle man." In my office ultrasound suite, I find that many parathyroid adenomas require "real time" visualization. In other words, the glands are easier to "see" in real time as I actually move the ultrasound probe over them, rather than in the static pictures that I snap and review later. Patients also appreciate the fact that we take an ultrasonographic tour of the neck together, by virtue of the LG flat screen LCD panel that I have suspended over the examining table (for patient convenience and education).

Finally, when we contemplate minimally invasive parathyroid surgery at FTLES, we must be absolutely certain that there are no anatomic thyroid, parathyroid or vascular problems that will make our surgery incomplete or unsuccessful. In this regard, ultrasound is the best technology for finding small, unsuspected thyroid cancers that need to be removed along with enlarged parathyroids. The saddest outcome for a minimally invasive neck surgery occurs when an unsuspected parathyroid adenoma or a thyroid cancer is mistakenly left in the neck due to inadequate pre-operative ultrasound localization. For these reasons, we at Fort Lauderdale Endocrine Surgery require competent neck ultrasonography prior to any neck surgery. To make sure that the procedure is adequate, we do it ourselves using a state-of the art Siemens Acuson X-150 office ultrasound device.