Parathyroidectomy under Local Anesthesia: A Case Report

rimary hyperparathyroidism is a common diseases (affecting about 1% of  adult population), it is either due to excessive secretion of parathyroid hormone by a single adenoma  (in 85%) or hyperplasia of parathyroid glands (in 15%) ^1,2,3. Women are affected twice as  often as in men, usually patients are middle-aged (40–65 years)^1,4. Primary hyperparathyroidism diagnosis is based on serum calcium, phosphate and parathyroid hormone³. Parathyroidectomy is the curative treatment ^2,5,6. Postoperative hypocalcaemia after parathyroidectomy is expected and usually resolved after 4^th postoperative day^6,7. The aim of presentation is to increase awareness of this common disease and to present the value of  parathyroidectomy under local anesthesia.

Case report:

This case report was approved by the research ethics committee of college of medicine, University of Mosul. A fifty four old years women (S YS) presented at 23^th of September 2018 with severe generalized bone pain with inability to move, her complaint started two years ago as generalized bone pain with multiple fractures without trauma , fracture left shaft of femur treated surgically by plate and screws 10 months ago, lower part of right femur get fracture and treated conservatively, left forearm fractured spontaneously and treated conservatively ended by forearm deformity. The patient complained of anorexia, weight loss, repeated attacks of abdominal pain, polyuria, history of renal stones, repeated attacks of dysuria,  sleep disturbance and depression. On examination, the patient look ill, bed ridden, cannot move here limbs with external rotation an deformity of both thighs. Left forearm was deformed, she refused any trail of passive or active movement, tenderness all over the bones, on physical examination pulse rate was 78 per minute, blood pressure was 110/70 mm mg, respiratory rate 18 per minute, abdomen soft and there is no palpable masses. A nodule of three cm diameter was found below the level of the thyroid cartilage on left side, there was no palpable lymphadenopathy in the submandibular region, no other palpable neck swelling detected.

   Radiological examination of both thighs showed marked osteoporosis and multiple  osteolytic lesions and cystic changes in bones. Left femur shows internal fixation by plate and screws  and  cystic changes in bones, right femur shows multiple cystic changes with malunited fracture in lower femur and marked osteoporosis (Fig. 1).

   Pelvic x-ray shows deformity of pelvis and fracture right femoral neck with varus deformity, left femoral neck shows varus deformity of head. Left forearm show malunited fracture of distal radius and ulna with marked osteoporosis. Hand x-ray shows  cortical resorption of the middle phalanges which is pathognomonic for primary hyperparathyroidism (Fig. 2).

Figure 1: Radiological examination of both femora shows marked osteoporosis , multiple  osteolytic lesions, cystic changes in bones, and  internal fixation by plate and screws  in left femur .

Figure 2:  X- ray of right index shows  cortical resorption of the middle phalanges which is pathognomonic for primary hyperparathyroidism.

   Laboratory tests revealed an elevated serum calcium level of 3.1  mmol/L (normal range: 2.0–2.8  mmol/L), and low serum phosphorus level of 0.72  mmol/L (normal range: 0.81–1.65  mmol/L). The serum alkaline phosphatase was elevated 397  IU/L (normal range: 24–82  IU/L). There was normal serum creatinine 0.9 mg/dl, blood urea 18mg/dl, serum albumin 4.2 gm./dl. Serum parathyroid hormone was 1157 pg. /ml (normal range: 6.5 – 36.8), the serum parathyroid hormone measured by chemiluminescent enzyme labeled immunometric technique (IMMULITE 1000 Siemens- Germany). Ultrasonography done to the anterior part of neck which shows well define mass at the left lower parathyroid gland, rounded, 2.5 cm in diameter, without cystic lesion or calcification.

   The patients referred to general surgery unit on an assumptive diagnosis of primary hyperparathyroidism caused by adenoma for parathyroidectomy. The patient prepared for surgical treatment but she was unfit for general anesthesia.  A decision for  surgery under local  anesthesia was done. At first of October  2018, the patient admitted to Alzahrawy private hospital, the patient  transfer to operating room and local xylocaine  infiltration  (8 ml of 2% without adrenaline) was carried out with cervical plexus block, skin prepared for surgery, and through a transverse cervical collar incision, the cervical fascia is divided and muscles retracted. The thyroid gland lobes dissected and lobes retracted medially, recurrent laryngeal nerves and blood vessels identified. The adenoma of left inferior parathyroid gland identified, the other parathyroid glandes identified and look normal, the glandes excised except  the deep half of right superior parathyroid gland, hemostasis carried out and wound closed in layers. Intraoperative measurement of parathyroid hormone in not applied in our patient because it is not available at time of surgery.

   Intravenous fluid was given postoperatively with 10 gram calcium gluconate on fusion, daily 600000  IU of one alpha cholecalceferol intramuscularly,  with repeated measurement of serum calcium in first and second postoperative days. In third postoperative day patient felt well, and she can swallow without any difficulty with normal voice, serum parathyroid hormone was 8.4  pg/ml, patient discharged on 6 gram oral calcium carbonate given with 0.5 µgm  one alpha cholecalceferol daily, and  the patient advised to drink a lot of water to maintain hydration. Histopathological examination of removed nodule  confirmed  the diagnosis of parathyroid adenoma. Two weeks later patient reported marked absence of bone pain, with normal serum calcium, phosphate and parathyroid hormone. The patient followed up monthly for consecutive three months, the serum calcium, phosphate and parathyroid hormone  maintained normal, and  the bone re-mineralized  gradually.

DISCUSSION

The delay in diagnosis and treatment is expected in our local community with marked deficiency in medical care  after  years of destructive war in our region and wide deficiency of medical facilities. In our patient, the diagnosis of   primary hyperparathyroidism was dependent on blood biochemistry , neck ultrasonography was utilized for localization of adenoma due to absences of  other localization method in our medical facilities. Ultrasonography is a sensitive, specific, and cost-effective imaging modality for preoperative localization, and evaluation of parathyroid adenoma size^8,9,10. Ultrasonography had  comparable accuracy to nuclear medicine -based studies (Sestambi scanning), CT scan had disadvantage of excessive irradiation, MRI is not commonly used to image the parathyroid gland ^{8,9, 10}. Venous sampling and parathyroid angiography and applied for recurrence¹⁰.

   Musculoskeletal system remains the most common system affected due to primary hyperparathyroidism followed by renal and gastrointestinal system⁸. Parathyroidectomy is successful in all patients of primary hyperparathyroidism ^10,11. Indication for surgical treatment of hyperparathyroidism, are marked unremitting hypercalcaemia, recurrent renal stones, nephrocalcinosis and sever bone changes ^{1, 6,8}. Excision of adenoma containing parathyroid is good option in treatment of primary hyperparathyroidism, but this diagnosis can be misleading in patients with history of chronic renal disease^6,8. For this we excised two and half of other three normal looking parathyroid glands to minimize the risk of recurrence^6,8. We used local anesthesia in our patient because she was unfit to general anesthesia, the local anesthesia is safe, easy to used , and reduce the complications and cost of surgery¹⁰.

   Postoperative calcium supplementation is essential to prevent development of hypocalcemia. Active derivative of vitamin D should be given preoperatively and postoperatively to maintain normal level of calcium ^12,13. Normal level of  serum calcium, phosphate, parathyroid hormone in postoperative follow-up considered as full success of surgical treatment^7,13,14. Lastly we should be aware about possibility of  hyperparathyroidism if there is pathological fractures or generalized bone pain.