Annals of Surgical Oncology

, Volume 19, Issue 12, pp 3823–3826 | Cite as

Tumor Proximity to the Recurrent Laryngeal Nerve in Patients with Primary Hyperparathyroidism Undergoing Parathyroidectomy

  • Brian R. Untch
  • Mohamed A. Adam
  • Melissa E. Danko
  • Michael E. Barfield
  • Darshana Dixit
  • Randall P. Scheri
  • John A. Olson
Endocrine Tumors



Recurrent laryngeal nerve (RLN) injury is a rare complication for patients undergoing neck exploration for primary hyperparathyroidism (pHPT). Distances between RLNs and parathyroid adenomas have not been previously published. In this study we used a RLN monitor to identify the RLN and to measure the proximity to parathyroid tumors.


Patients with pHPT (n = 136) underwent neck exploration and had the clinical data recorded prospectively. Adenomas were recorded in 1 of 4 locations (right upper, right lower, left upper, left lower). Measurement of RLN to adenoma distances were recorded intraoperatively with the gland in situ. The RLN location was confirmed with a RLN monitor.


The average RLN to adenoma distance was 0.52 ± 0.52 cm. Adenomas in the right upper position were significantly closer to the nerve (0.25 ± 0.39 cm) compared with adenomas in the left upper (0.48 ± 0.61 cm, p = .03), left lower (0.70 ± 0.53 cm, p < .001), and right lower position (1.02 ± 0.56 cm, p < .001). Left upper adenomas were also significantly closer to the nerve compared with right lower adenomas (p < .001). Adenomas in the right upper position abutted the nerve more often (47 %) compared with adenomas in other positions (p = .001). There were no perioperative characteristics that predicted tumor abutment. There were no permanent RLN injuries.


In patients with sporadic pHPT, parathyroid adenomas in the right upper location have, on average, greater proximity to the RLN and are more often directly abutting compared with adenomas in other locations.


Adenoma Recurrent Laryngeal Nerve Primary Hyperparathyroidism Parathyroid Adenoma Parathyroid Carcinoma 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Abadin SS, Kaplan EL, Angelos P. Malpractice litigation after thyroid surgery: the role of recurrent laryngeal nerve injuries, 1989–2009. Surgery. 2010;148:718–22.PubMedCrossRefGoogle Scholar
  2. 2.
    Dackiw AP, Rotstein LE, Clark OH. Computer-assisted evoked electromyography with stimulating surgical instruments for recurrent/external laryngeal nerve identification and preservation in thyroid and parathyroid operation. Surgery. 2002;132:1100–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Randolph GW, Dralle H, International Intraoperative Monitoring Study Group, et al. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope. 2011;121:S1–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Harrison BJ, Triponez F. Intraoperative adjuncts in surgery for primary hyperparathyroidism. Langenbecks Arch Surg. 2009;394:799–809.PubMedCrossRefGoogle Scholar
  5. 5.
    Allendorf J, Digorgi M, Spanknebel K, Inabnet W, Chabot J, Logerfo P. 1112 consecutive bilateral neck explorations for primary hyperparathyroidism. World J Surg. 2007;31:2075–80.PubMedCrossRefGoogle Scholar
  6. 6.
    Untch BR, Adam MA, Scheri RP, Bennett KM, Dixit D, Webb C, et al. Surgeon-performed ultrasound is superior to 99Tc-sestamibi scanning to localize parathyroid adenomas in patients with primary hyperparathyroidism: results in 516 patients over 10 years. J Am Coll Surg. 2011;212:522–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Chen H, Mack E, Starling JR. A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy: which is most reliable? Ann Surg. 2005;242:375–80.PubMedGoogle Scholar
  8. 8.
    Untch BR, Barfield ME, Dar M, Dixit D, Leight GS Jr, Olson JA Jr. Impact of 25-hydroxyvitamin D deficiency on perioperative parathyroid hormone kinetics and results in patients with primary hyperparathyroidism. Surgery. 2007;142:1022–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Lew JL, Irvin GL 3rd. Focused parathyroidectomy guided by intra-operative parathormone monitoring does not miss multiglandular disease in patients with sporadic primary hyperparathyroidism: a 10 year outcome. Surgery. 2009;146:1021–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Cayo AK, Sippel RS, Schaefer S, Chen H. Utility of intraoperative PTH for primary hyperparathyroidism due to multigland disease. Ann Surg Oncol. 2009;16:3450–4.PubMedCrossRefGoogle Scholar
  11. 11.
    Adam MA, Untch BR, Danko ME, Stinnett S, Dixit D, Koh J, et al. Severe obesity is associated with symptomatic presentation, higher parathyroid hormone levels, and increased gland weight in primary hyperparathyroidism. J Clin Endocrinol Metab. 2010;95:4917–24.PubMedCrossRefGoogle Scholar
  12. 12.
    Moreno MA, Callender GG, Woodburn K, Edeiken-Monroe BS, Grubbs EG, Evans DB, et al. Common locations of parathyroid adenomas. Ann Surg Oncol. 2011;18:1047–51.PubMedCrossRefGoogle Scholar
  13. 13.
    Landry CS, Grubbs EG, Morris GS, Turner NS, Holsinger FC, Lee JE, et al. Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands. Surgery. 2011;149:549–55.PubMedCrossRefGoogle Scholar
  14. 14.
    Solbiati L, Giangrande A, De Pra L, Bellotti E, Cantù P, Ravetto C. Percutaneous ethanol injection of parathyroid tumors under US guidance: treatment for secondary hyperparathyroidism. Radiology. 1985;155:607–10.PubMedGoogle Scholar
  15. 15.
    Chen HH, Lin CJ, Wu CJ, Lai CT, Lin J, Cheng SP, et al. Chemical ablation of recurrent and persistent secondary hyperparathyroidism after subtotal parathyroidectomy. Ann Surg. 2011;253:786–90.PubMedCrossRefGoogle Scholar
  16. 16.
    Harman CR, Grant CS, Hay ID, Hurley DL, van Heerden JA, Thompson GB, et al. Indications, technique, and efficacy of alcohol injection of enlarged parathyroid glands in patients with primary hyperparathyroidism. Surgery. 1998;124:1011–9.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • Brian R. Untch
    • 1
  • Mohamed A. Adam
    • 2
  • Melissa E. Danko
    • 2
  • Michael E. Barfield
    • 2
  • Darshana Dixit
    • 2
  • Randall P. Scheri
    • 2
  • John A. Olson
    • 2
  1. 1.Department of SurgeryMemorial Sloan-Kettering Cancer CenterNew YorkUSA
  2. 2.Department of SurgeryDuke University Medical CenterDurhamUSA

Personalised recommendations