Abstract
Multigland disease (MGD) is the Achilles heel of all parathyroid imaging modalities. MGD can be difficult to recognize preoperatively and may present a challenge for accurate localization. MGD comes in the form of double adenomas, asymmetric multigland hyperplasia, and rarely supernumerary or ectopic disease. This chapter provides patient scenarios to illustrate clinical features that contribute to the challenge of accurately localizing MGD: smaller and variably sized parathyroid glands compared to single adenomas, positioning deep in the tracheoesophageal groove, asymmetrically sized glands, uncommon presentations serving as a distractor from considering MGD, the discrimination of intrathyroidal glands from thyroid nodules, and inherent characteristics of parathyroid glands that affect uptake of radiotracers and imaging agents.
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Ultrasound cine clip left upper parathyroid gland, transverse view (MP4 1805 kb)
Ultrasound cine clip left upper parathyroid gland, longitudinal view (MP4 1799 kb)
Ultrasound cine clip left lower parathyroid gland, longitudinal view. This parathyroid is situated in the central neck fatty tissue and is less hypoechoic and discreet compared to the other enlarged glands. At surgery, it was also least abnormal in appearance and suitable to save in situ as a remnant. The esophageal wall layers are discernable at the bottom of the frame (MP4 1707 kb)
Ultrasound cine clip right lower parathyroid transverse view without vascular flow (MP4 1685 kb)
Ultrasound cine clip of right lower parathyroid transverse view with vascular flow. The parathyroid remains hypoechoic with a peripheral vascular signal on its anterior surface against the overlying thyroid lobe (MP4 1584 kb)
Ultrasound cine clip right lower parathyroid gland, longitudinal view. A small thyroid cyst is seen within the right thyroid lobe (MP4 1798 kb)
Ultrasound cine clip of right-sided parathyroids. A small section of the oval right lower parathyroid gland is seen at the top of the screen just at the tip of the thyroid pole. Meanwhile, only with significant transducer pressure is a large hypoechoic oval evident in the bottom center of the cine clip. This represents the right upper parathyroid gland residing deep in the tracheoesophageal groove. Transverse views did not show this upper parathyroid gland clearly (MP4 1760 kb)
Ultrasound cine clip right upper intrathyroidal parathyroid, transverse view (MP4 1440 kb)
Ultrasound cine clip right upper parathyroid, longitudinal view (MP4 1807 kb)
Ultrasound cine clip in transverse orientation shows an oval smooth hypoechoic structure deep the thyroid lobe and lateral to the trachea. This is the enlarged right lower parathyroid gland. Within the thyroid and two hypoechoic nodules with an initial hint of an interrupted peripheral rim of calcifications (MP4 1591 kb)
Ultrasound cine clip of right thyroid nodules with lateral nodule features demonstrating high suspicion for malignancy: interrupted peripheral rim of calcifications and irregular margins (MP4 1813 kb)
Ultrasound cine clip of left thyroid lobe in longitudinal view that shows a calcified thyroid nodule in the midportion and a large lower parathyroid gland with solid and cystic changes (common to see in secondary and tertiary hyperparathyroidism) (MP4 1816 kb)
Ultrasound cine clip left upper parathyroid, longitudinal view, captured via two different point-of-care ultrasound machines: ultrasound from operating room (MP4 7126 kb)
Ultrasound cine clip left upper parathyroid, longitudinal view, captured via two different point-of-care ultrasound machines: ultrasound from outpatient clinic (MP4 6055 kb)
Ultrasound cine clip left upper parathyroid, transverse view. Toward the end of the cine clip a suggestion of a structure that could represent an enlarged left lower parathyroid is seen. Remember, normal parathyroid glands are not detectable by ultrasound. Thus, though mildly enlarged, this structure deserves consideration as an abnormal parathyroid (MP4 6053 kb)
Ultrasound cine clip right upper parathyroid, transverse view (MP4 1674 kb)
Ultrasound cine clip with left inferior thyroid artery branching that mimics a parathyroid density (but is not). Meanwhile, a teardrop-shaped hypoechoic density rests anteriorly on the right surface of the trachea representing a true enlarged parathyroid (MP4 1104 kb)
Ultrasound cine clip in patient with MEN1 showing no parathyroid abnormalities. The left inferior thyroid artery is seen branching adjacent to the Tubercle of Zuckerkandl (isoechoic cleft of the thyroid). The carotid artery, esophagus, and paraspinous muscle are visible (MP4 1308 kb)
Ultrasound cine clip in patient with MEN1 showing right upper parathyroid oval density. The esophagus is seen deep to the trachea and moves with swallowing. A large paraspinous muscle is lateral to the area of interest for the parathyroid oval density and immediately above the bright hyperechoic line of the vertebral bone (MP4 1777 kb)
Ultrasound cine clip in patient with MEN1 showing right upper parathyroid in longitudinal view (MP4 1634 kb)
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Chockalingham, V., Milas, M., Sturgeon, C. (2017). Ultrasound Case Vignettes: Multigland Parathyroid Disease. In: Milas, M., Mandel, S.J., Langer, J.E. (eds) Advanced Thyroid and Parathyroid Ultrasound. Springer, Cham. https://doi.org/10.1007/978-3-319-44100-9_26
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DOI: https://doi.org/10.1007/978-3-319-44100-9_26
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