Intravagal ectopic parathyroid adenoma: Challenging perioper
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Persistent hyperparathyroidism is usually due to a missed parathyroid adenoma, which can be located at variable though well-described locations within the neck and mediastinum due to the gland's embryological descent.

This report describes a rare case of an intravagal parathyroid adenoma that illustrates the benefit of multiple localisation modalities.

Parathyroid adenomas are managed with surgical excision. Up to 10% of patients have persistent hyperparathyroidism after primary intervention, most commonly attributed to a missed parathyroid adenoma. These cases require careful preoperative localisation as ectopic locations are more likely. Ectopic parathyroid glands can be found throughout the path of their descent or co-located with embryological tissues.

A 43-year-old man was referred with primary hyperparathyroidism. Sestamibi demonstrated uptake of equivocal suspicion posterior to the right hemithyroid; ultrasound of this area was negative. Initial exploration failed to find an adenoma or left inferior parathyroid. Repeat sestamibi, 4D-CT and selective venous sampling localised the adenoma to the left upper neck. An intravagal parathyroid adenoma was identified intraoperatively with gamma probe and completely excised. The patient was biochemically cured and had normal vocal cord function at follow up.

Conclusively, In all cases of persistent hyperparathyroidism, best possible pre-operative localisation of an adenoma before further operative intervention is vital. Surgeons should be aware of rare sites of ectopia and pitfalls of imaging. Use of intraoperative adjuncts, such as the gamma probe in this case, can be useful in definitive intraoperative localisation. Excision of parathyroid tissue from within the vagus nerve can be accomplished safely without permanent morbidity.