Atlas of Sonography of Parathyroid

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Acknowledgements
Contents
About the Author
Abbreviations
1: Introduction to Parathyroid Sonography
	1.1	 Anatomy and Embryology of Parathyroid Glands
	1.2	 Vascular Anatomy
	1.3	 Nerve Relations
	1.4	 Microscopic Anatomy
	1.5	 Embryological Anatomy
		1.5.1 Origin, Migration and Eutopic Locations
	1.6	 Calcium Metabolism and Role of Parathyroid Hormone and Calcitonin
	1.7	 Hyperparathyroidism
	1.8	 Types of Hyperparathyroidism
	1.9	 Clinical Symptoms of Hyperparathyroidism
	1.10	 Biochemical Investigations: A Practical Approach to Hypercalcaemia
	1.11	 Approach to Hypercalcaemia
	1.12	 Imaging
		1.12.1 Guiding Principles of Parathyroid Imaging
		1.12.2 Parathyroid Scintigraphy: Tc-99m Sestamibi SPECT and SPECT/CT
		1.12.3 Four-Dimensional Computed Tomography (4D CT)
		1.12.4 Ultrasound of the Neck for Localization of the Parathyroid Glands
		1.12.5 Patient Positioning for Neck Ultrasound
		1.12.6 Ultrasound
			1.12.6.1	 Transducer Selection
			1.12.6.2	 Ultrasound Technique
		1.12.7 Key Greyscale Ultrasound Features
		1.12.8 Typical Parathyroid Adenoma
			1.12.8.1	 Key Colour Doppler Ultrasound Features
		1.12.9 Role of Spectral Doppler in Parathyroid Evaluation
		1.12.10 Role of Contrast-Enhanced Ultrasound (CEUS) in Parathyroid Evaluation
		1.12.11 Role of Shear Wave Elastography in Parathyroid Nodule Evaluation
		1.12.12 Differential Diagnosis of an Orthotopic Parathyroid Adenoma
			1.12.12.1	 Lymph Node
			1.12.12.2	 Blood Vessel
			1.12.12.3	 Thyroid Nodule
			1.12.12.4	 Sequestrated Thyroid Tissue
			1.12.12.5	 Internal Jugular Vein Thrombosis
			1.12.12.6	 Schwannoma of the Vagus Nerve in the Neck
			1.12.12.7	 Carotid Body Tumour
	1.13	 Medical Management
		1.13.1 Calcium Supplementation/Restriction
	1.14	 Indications for Surgery
		1.14.1 Skeletal Guidelines
		1.14.2 Renal Guidelines
		1.14.3 Histopathology
		1.14.4 Parathyroid Adenoma
		1.14.5 Parathyroid Hyperplasia
		1.14.6 Parathyroid Carcinoma
	References
2: Sonography of a Typical Parathyroid Adenoma: Solitary Parathyroids as Seen on Ultrasound
	2.1	 Introduction
	2.2	 Case 1
		2.2.1	 Bio-Clinical Parameters
		2.2.2	 Technetium-99m Sestamibi Scan
		2.2.3	 Ultrasound Neck
		2.2.4	 Management
	2.3	 Case 2
		2.3.1	 Bio-Clinical Parameters
		2.3.2	 Imaging
		2.3.3	 Management
	2.4	 Case 3
		2.4.1	 Bio-Clinical Parameters
		2.4.2	 Management
	2.5	 Case 4
		2.5.1	 Clinical Details
		2.5.2	 Bio-Clinical Parameters
		2.5.3	 Technetium-99m Sestamibi Scan
		2.5.4	 Management
	2.6	 Case 5
		2.6.1	 Bio-Clinical Parameters
		2.6.2	 “Tc-99m Sestamibi” Scan Findings
		2.6.3	 Management
	2.7	 Case 6
		2.7.1	 Bio-Clinical Parameters
		2.7.2	 Ultrasound of the Neck for Parathyroid
		2.7.3	 Management
	2.8	 Case 7
		2.8.1	 Bio-Clinical Parameters
		2.8.2	 Ultrasound Neck
			2.8.2.1	 Findings
		2.8.3	 Management
	2.9	 Case 8
		2.9.1	 Bio-Clinical Parameters
		2.9.2	 Ultrasound Neck
		2.9.3	 Skeletal Survey
		2.9.4	 Management
	2.10	 Case 9
		2.10.1	 Bio-Clinical Parameters
		2.10.2	 Ultrasound Neck
		2.10.3	 Management
	2.11	 Case10
		2.11.1	 Bio-Clinical Parameters
		2.11.2	 Ultrasound Neck
		2.11.3	 Management
	2.12	 Case 11
		2.12.1	 Bio-Clinical Parameters
		2.12.2	 Management
	2.13	 Discussion
	2.14	 Management
	2.15	 Conclusion
	References
3: Atypical Sonographic Appearances of Enlarged Parathyroids
	3.1	 Introduction
	3.2	 Changes in the Shape of Adenoma
		3.2.1	 Case 1
			3.2.1.1	 Bio-Clinical Parameters
			3.2.1.2	 Imaging
			3.2.1.3	 Ultrasound Neck
			3.2.1.4	 Discussion of the Neck Ultrasound Findings
			3.2.1.5	 Management
		3.2.2	 Case 2
			3.2.2.1	 Bio-Clinical Parameters
			3.2.2.2	 Imaging
			3.2.2.3	 Ultrasound Neck
			3.2.2.4	 Management
		3.2.3	 Case 3
			3.2.3.1	 Bio-Clinical Parameters
			3.2.3.2	 Ultrasound Neck
			3.2.3.3	 Discussion of the Ultrasound Findings
			3.2.3.4	 Management
		3.2.4	 Discussion
	3.3	 Cystic Changes in Parathyroid Lesions
		3.3.1	 Case 4
			3.3.1.1	 Bio-Clinical Parameters
			3.3.1.2	 Imaging
				Technetium-99m Sestamibi Scan
			3.3.1.3	 Ultrasound Neck
			3.3.1.4	 Management
		3.3.2	 Case 5
			3.3.2.1	 Bio-Clinical Parameters
			3.3.2.2	 Management
			3.3.2.3	 Discussion: Parathyroid Cystic Changes and Parathyroid Cysts
		3.3.3	 Case 6
			3.3.3.1	 Bio-Clinical Parameters
			3.3.3.2	 Ultrasound Neck
			3.3.3.3	 Management
			3.3.3.4	 Discussion: Parathyroid Haemorrhage
	3.4	 Parathyroid Calcification
		3.4.1	 Case 7
			3.4.1.1	 Bio-Clinical Parameters
			3.4.1.2	 Ultrasound Neck
			3.4.1.3	 Management
			3.4.1.4	 Discussion: Parathyroid Calcifications
	3.5	 Altered Echotexture and Lobulations in Parathyroid Lesions
		3.5.1	 Case 8
			3.5.1.1	 Bio-Clinical Parameters
			3.5.1.2	 Imaging
			3.5.1.3	 Management
			3.5.1.4	 Discussion: Bilobed Parathyroid Adenoma
		3.5.2	 Case 9
			3.5.2.1	 Bio-Clinical Parameters
			3.5.2.2	 Ultrasound Neck
			3.5.2.3	 Management
		3.5.3	 Case 10
			3.5.3.1	 Bio-Clinical Parameters
			3.5.3.2	 Ultrasound
			3.5.3.3	 Management
		3.5.4	 Case 11
			3.5.4.1	 Bio-Clinical Parameters
			3.5.4.2	 Ultrasound Neck Findings
			3.5.4.3	 Management
	3.6	 Discussion
	3.7	 Conclusion
	References
4: Sonography of Large Parathyroid Adenomas
	4.1	 Introduction
	4.2	 Case 1
		4.2.1	 Bio-Clinical Parameters
		4.2.2	 Technetium-99m Sestamibi Scan
		4.2.3	 Ultrasound Neck Findings
		4.2.4	 Management
	4.3	 Case 2
		4.3.1	 Bio-Clinical Parameters
		4.3.2	 Ultrasound Neck
			4.3.2.1	 Findings
		4.3.3	 Management
		4.3.4	 Discussion
	4.4	 Case 3
		4.4.1	 Bio-Clinical Parameters
		4.4.2	 Findings: Technetium-99m sestamibi scan
		4.4.3	 Ultrasound Neck
			4.4.3.1	 Findings
		4.4.4	 Management
	4.5	 Case 4
		4.5.1	 Bio-Clinical Parameters
		4.5.2	 Technetium-99m Parathyroid scan
		4.5.3	 Ultrasound Neck
		4.5.4	 Management
	4.6	 Case 5
		4.6.1	 Bio-Clinical Parameters
		4.6.2	 99m-Tc Parathyroid Scan
		4.6.3	Findings
		4.6.4	 Ultrasound Neck
		4.6.5	 Management
	4.7	 Case 6
		4.7.1	 Bio-Clinical Parameters
		4.7.2	 Ultrasound Neck
			4.7.2.1	 Findings
		4.7.3	 Management
	4.8	 Case 7
		4.8.1	 Bio-Clinical Parameters
		4.8.2	 Ultrasound Neck
			4.8.2.1	 Findings
		4.8.3	 Management
	4.9	 Case 8
		4.9.1	 Bio-Clinical Parameters
		4.9.2	 Ultrasound Neck
			4.9.2.1	 Findings
		4.9.3	 Management
	4.10	 Discussion
	References
5: Role of Ultrasound in Evaluation of Ectopic Parathyroid Glands
	5.1	 Introduction
	5.2	 Case 1
		5.2.1	 Bio-Clinical Parameters
		5.2.2	 Ultrasound Neck
			5.2.2.1	 Findings
		5.2.3	 Management
	5.3	 Case 2
		5.3.1	 Bio-Clinical Parameters
		5.3.2	 Management
	5.4	 Case 3
		5.4.1	 Bio-Clinical Parameters
		5.4.2	 Ultrasound Neck
		5.4.3	 Management
	5.5	 Case 4
		5.5.1	 Bio-Clinical Parameters
		5.5.2	 Ultrasound Neck
			5.5.2.1	 Findings
		5.5.3	 Management
	5.6	 Case 5
		5.6.1	 Bio-Clinical Parameters
		5.6.2	 Ultrasound Neck
		5.6.3	 Management
	5.7	 Case 6
		5.7.1	 Bio-Clinical Parameters
		5.7.2	 Ultrasound Neck
		5.7.3	 Management
	5.8	 Case 7
		5.8.1	 Bio-Clinical Parameters
		5.8.2	 Ultrasound Neck
			5.8.2.1	 Findings
		5.8.3	 Management
	5.9	 Case 8
		5.9.1	 Bio-Clinical Parameters
		5.9.2	 Ultrasound Neck
			5.9.2.1	 Findings
		5.9.3	 Management
	5.10	 Case 9
		5.10.1	 Bio-Clinical Parameters
		5.10.2	 Ultrasound Neck
			5.10.2.1	 Findings
		5.10.3	 Management
	5.11	 Case 10
		5.11.1	 Bio-Clinical Parameters
		5.11.2	 Ultrasound Neck
			5.11.2.1	 Findings
		5.11.3	 Management
	5.12	 Case 11
		5.12.1	 Bio-Clinical Parameters
		5.12.2	 Ultrasound Neck
			5.12.2.1	 Findings
		5.12.3	 Management
	5.13	 Case 12
		5.13.1	 Bio-Clinical Parameters
		5.13.2	 Ultrasound Neck
			5.13.2.1	 Findings
	5.14	 Discussion
		5.14.1	 Ectopic Parathyroids Along the Thymo-thymic Tract
		5.14.2	 Intrathyroidal Parathyroids
	References
6: Sonographic Technique and Tips to Localize Tiny Parathyroids
	6.1	 Introduction
		6.1.1	 Management
	6.2	 Case 1
		6.2.1	 Bio-Clinical Parameters
		6.2.2	 Ultrasound Neck
		6.2.3	 Management
	6.3	 Case 2
		6.3.1	 Bio-Clinical Parameters
		6.3.2	 Ultrasound Neck
			6.3.2.1	 Findings
		6.3.3	 Management
	6.4	 Case 3
		6.4.1	 Bio-Clinical Parameters
		6.4.2	 Ultrasound Neck
		6.4.3	 Management
	6.5	 Case 4
		6.5.1	 Bio-Clinical Parameters
		6.5.2	 Ultrasound Neck
			6.5.2.1	 Findings
		6.5.3	 Management
	6.6	 Case 5
		6.6.1	 Bio-Clinical Parameters
		6.6.2	 Ultrasound Neck
			6.6.2.1	 Findings
		6.6.3	 Management
	6.7	 Case 6
		6.7.1	 Bio-Clinical Parameters
		6.7.2	 Ultrasound Neck
		6.7.3	 Management
	6.8	 Discussion
	References
7: Sonography of Dual and Multiple Parathyroid Adenomas in Sporadic Primary Hyperparathyroidism
	7.1	 Introduction
		7.1.1	 Management
	7.2	 Case 1
		7.2.1	 Bio-Clinical Parameters
		7.2.2	 Ultrasound Neck
			7.2.2.1	 Findings
				Right Inferior Parathyroid Gland
				Left Superior Parathyroid Gland
				Left Inferior Parathyroid Gland
		7.2.3	 Management
	7.3	 Case 2
		7.3.1	 Bio-Clinical Parameters
		7.3.2	 Ultrasound Neck
			7.3.2.1	 Findings
				Left Inferior Parathyroid
				Right Superior Parathyroid
				Right Inferior Parathyroid
		7.3.3	 Management
	7.4	 Discussion
	References
8: Role of Sonography in Hyperparathyroidism in Chronic Kidney Disease and Post-Renal Transplant Recipients
	8.1	 Introduction
	8.2	 Pathophysiology of Hyperparathyroidism in Renal Disease
		8.2.1	 Management
	8.3	 Case 1
		8.3.1	 Clinical Details
			8.3.1.1	 Bio-Clinical Parameters
			8.3.1.2	 Ultrasound Neck
				Findings
					Right Inferior Parathyroid
					Right Superior Parathyroid
					Left Superior Parathyroid
					Left Inferior Parathyroid
		8.3.2	 Management
	8.4	 Case 2
		8.4.1	 Bio-Clinical Parameters
		8.4.2	 Ultrasound Neck
			8.4.2.1	 Right Inferior Parathyroid
			8.4.2.2	 Left Inferior Parathyroid
		8.4.3	 Management
	8.5	 Case 3
		8.5.1	 Bio-Clinical Parameters
		8.5.2	 Ultrasound Neck
		8.5.3	 Management
	8.6	 Case 4
		8.6.1	 Bio-Clinical Parameters
		8.6.2	 Ultrasound Neck
			8.6.2.1	 Findings
				Right Superior Parathyroid
				Right Inferior Parathyroid
				Left Superior Parathyroid
		8.6.3	 Management
	8.7	 Case 5
		8.7.1	 Bio-Clinical Parameters
		8.7.2	 Ultrasound Neck
			8.7.2.1	 Findings
				Right Superior Parathyroid
				Right Inferior Parathyroid
				Left Superior Parathyroid
				Left Inferior Parathyroid
		8.7.3	 Management
	8.8	 Case 6
		8.8.1	 Bio-Clinical Parameters
		8.8.2	 Ultrasound Neck
			8.8.2.1	 Findings
				Left Inferior Parathyroid
				Left Superior Parathyroid
				Right Inferior Parathyroid
				Right Superior Parathyroid
		8.8.3	 Management
	8.9	 Case 7
		8.9.1	 Bio-Clinical Parameters
		8.9.2	 Ultrasound Neck
		8.9.3	 Management
	8.10	 Case 8
		8.10.1	 Bio-Clinical Parameters
		8.10.2	 Discussion: Altered Echotexture of parathyroid nodules
		8.10.3	 Management
	8.11	 Case 9
		8.11.1	 Bio-Clinical Parameters
		8.11.2	 Ultrasound Neck
			8.11.2.1	 Findings
				Left Superior Parathyroid
				Left Inferior Parathyroid
				Right Inferior Parathyroid
		8.11.3	 Management
	8.12	 Conclusion
	References
9: Sonography Findings in Parathyroid Carcinoma and Heterogenous Parathyroids
	9.1	 Introduction
	9.2	 Case 1
		9.2.1	 Bio-Clinical Parameters
		9.2.2	 Ultrasound Neck
		9.2.3	 Management
		9.2.4	 Post Operative Histopathology Findings
	9.3	 Case 2
		9.3.1	 Bio-Clinical Parameters
		9.3.2	 Ultrasound
		9.3.3	 Management
	9.4	 Case 3
		9.4.1	 Bio-Clinical Parameters
		9.4.2	 Ultrasound
			9.4.2.1	 Findings
		9.4.3	 Management
	9.5	 Discussion
	References
10: Ultrasound Evaluation of Parathyroid Adenoma with Co-Existent Thyroid Pathology
	10.1	 Introduction
	10.2	 Case 1
		10.2.1	 Bio-Clinical Parameters
			10.2.1.1	 Findings
		10.2.2	 Ultrasound Neck
		10.2.3	 Management
		10.2.4	 Discussion
	10.3	 Case 2
		10.3.1	 Bio-Clinical Parameters
		10.3.2	 Ultrasound Neck
		10.3.3	 Management
	10.4	 Case 3
		10.4.1	 Bio-Clinical Parameters
		10.4.2	 Ultrasound Neck
		10.4.3	 Management
		10.4.4	 Discussion
	10.5	 Case 4
		10.5.1	 Bio-Clinical Parameters
		10.5.2	 Ultrasound Neck
		10.5.3	 Management
		10.5.4	 Discussion
	References
11: Ultrasound Essentials in MEN Syndromes and Familial Hyperparathyroidism
	11.1	 Introduction
	11.2	 Case 1
		11.2.1	 Bio-Clinical Parameters
		11.2.2	 Ultrasound Neck
			11.2.2.1	 Findings
		11.2.3	 Discussion
		11.2.4	 Management
	11.3	 Case 2
		11.3.1	 Bio-Clinical Parameters
		11.3.2	 Ultrasound Neck
			11.3.2.1	 Findings
				Right Superior Parathyroid
				Right Inferior Parathyroid
				Left Superior Parathyroid
				Left Inferior Parathyroid
		11.3.3	 Management
	11.4	 Case 3
		11.4.1	 Bio-Clinical Parameters
		11.4.2	 Ultrasound Neck
			11.4.2.1	 Findings
				Right Inferior Parathyroid
				Right Superior Parathyroid
				Left Inferior Parathyroid
				Left Superior Parathyroid
		11.4.3	 Management
	11.5	 Case 4
		11.5.1	 Bio-Clinical Parameters
		11.5.2	 Ultrasound Neck
			11.5.2.1	 Findings
				Right Superior Parathyroid
				Right Inferior Parathyroid
				Left Superior Parathyroid
				Left Inferior Parathyroid
		11.5.3	 Management
	11.6	 Discussion
	11.7	 Case 5
		11.7.1	 Bio Clinical Parameters
			11.7.1.1	 Radiograph of Both Hands and Skull
				Findings
			11.7.1.2	 99m-Technetium Parathyroid Scan
		11.7.2	 Ultrasound Neck
		11.7.3	 Management
	11.8	 Case 6
		11.8.1	 Bio Clinical Parameters
		11.8.2	 Ultrasound Neck
			11.8.2.1	 Findings
		11.8.3	 Management
	11.9	 Case 7
		11.9.1	 Bio Clinical Parameters
		11.9.2	 Ultrasound Neck
			11.9.2.1	 Right Inferior Parathyroid
			11.9.2.2	 Left Inferior Parathyroid
		11.9.3	 Management
		11.9.4	 Discussion
			11.9.4.1	 MEN1
			11.9.4.2	 MEN2
	References
12: Essentials of Surgical Perspectives of Parathyroid Surgery
	12.1	 Indications for Exploration
	12.2	 Surgical Strategy and Approach to Exploration
	12.3	 Technique of Parathyroidectomy
		12.3.1	 Positioning of the Patient
		12.3.2	 Exploration of the Neck
		12.3.3	 Minimally Invasive Techniques
		12.3.4	 Closure of the Incision
		12.3.5	 Postoperative Care
	References
Afterword