Surgical management of hyperparathyroidism

Abstract

The presentation, diagnosis, and operative approach to hyperparathyroidism have undergone great changes since it was first recognized as a clinical entity in 1925. The classic case of Captain Charles Martell offers guidance that is still useful (1). This previously vigorous sea captain had decreased 7 inches in height, developed the multiple skeletal deformities of osteitis fibrosis cystica, and passed gravel at the end of urination. In the course of six operations for hyperparathyroidism at the Massachusetts General Hospital, at least two normal parathyroids were removed. At a seventh procedure an adenoma in the anterior mediastinum was discovered and removed through a sternal splitting incision. Postoperatively he became hypocalcemic. Six weeks thereafter he died of tetany and laryngospasm during an attempt to remove a kidney stone. The lessons from this case remain with us today-the limited ability to predict ectopic parathyroid adenomas that may be beyond the reach of a neck incision, and the realization that the removal of normal parathyroid glands can be devastating.