Otolaryngology – Head and Neck Surgery
Minimally Invasive Radioguided Parathyroidectomy (MIRP)
The Division of Otolaryngology − Head and Neck Surgery at Penn State Health Milton S. Hershey Medical Center is the only team in the region to offer minimally invasive radioguided parathyroidectomy. This minimally invasive surgical option gives patients a faster recovery and less pain. Often, patients can go home the same day as their surgery.
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Minimally Invasive Radioguided Parathyroidectomy
A safer and less invasive approach to surgically treat hyperparathyroidism
Hyperparathyroidism is a condition that causes high blood-calcium levels in nearly 100,000 Americans every year. The disease is caused if one or more of the four tiny parathyroid glands located behind the thyroid in the neck become enlarged and produce too much parathyroid hormone (PTH). This is usually caused by a benign tumor called a parathyroid adenoma. Hyperparathyroidism is a chronic condition that affects two out of every 1,000 people, and sometimes causes osteoporosis, kidney stones, abdominal problems, depression, and fatigue, among other illnesses. Hyperparathyroidism can be successfully treated by surgically removing the abnormal parathyroid gland—or in some cases—multiple glands.
David Goldenberg, MD, Professor of Surgery in the Division of Head and Neck Surgery, has been performing minimally invasive radioguided parathyroid surgery to treat primary hyperparathyroidism for more than twelve years. His patients experience rapid relief with little scarring or side effects.
My goal as a thyroid and parathyroid surgeon is to provide my patients with the best and safest surgical care for their endocrine surgical disease.”
Frequently asked questions
Q: What is minimally invasive radioguided parathyroidectomy (MIRP)?
A: Minimally invasive radioguided parathyroidectomy, or MIRP, is a surgical procedure used to treat patients diagnosed with primary hyperparathyroidism. A safer and less invasive approach to a traditional parathyroidectomy, MIRP can usually be performed through a 1.5-inch incision in the neck. Before MIRP, surgeons searched for and removed the faulty parathyroid gland through a large incision. This approach often required surgical exploration of the neck.
Q: How is the surgery performed?
A: Before surgery, patients are injected with a radioactive material that washes out quickly from the thyroid. It remains only in the diseased parathyroid gland (adenoma), and is not absorbed readily by healthy parathyroid glands. Two hours later, the parathyroid is viewed on a radioisotope (sestamibi) scan to help locate the abnormal parathyroid gland and is found through the incision using a hand-held radiation detector. Usually, a 1.5-inch incision is made precisely over the spot of the offending gland, and it is surgically removed. While the patient is still asleep, a rapid blood test is taken to look for a drop in PTH levels. Within ten minutes of removing the offending adenoma, the levels will have dropped 50 percent compared to the pre-op test.
Q: How long is the surgery?
A: The procedure takes less than one hour.
Q: How long do patients stay in the hospital after surgery?
A: Because the procedure is minimally invasive, most patients go home the same day of the procedure—usually just a few hours later.
Q: What is recovery like?
A: MIRP is a minimally invasive procedure. Benefits include less pain, less scarring, and shorter recovery time.
Q: Are there any risks involved with this procedure?
A: As with any surgery, there are risks. There is a low risk of nerve damage to the vocal cord, and there is a small risk of developing chronically low calcium levels.
Q: Does MIRP always cure hyperparathyroidism?
A: The cure rate is significantly higher than any other parathyroid operation and the complication rate is near zero (significantly less than 1 percent when performed by expert parathyroid surgeons).
Q: Are all parathyroid problems managed with MIRP?
A: No, there are less common types of hyperparathyroidism that are managed either medically (with medicine) or with other various types of surgical procedures.
If you are a referring physician with questions about MIRP or other parathyroid surgery, or to find out if your patient is a candidate for this procedure, please call 717-531-6822.
If you are a patient diagnosed with hyperparathyroidism and would like to schedule an appointment, please call 717-531-6822.
- Minimally Invasive Parathyroidectomy. Operative Techniques in Otolaryngology-Head and Neck Surgery. Shah-Becker, S., Goldenberg, D. (2016) 27, 152-156.
- Surgical Exploration for Hyperparathyroidism. Shah-Becker, S., Goldenberg, D. Operative Techniques in Otolaryngology-Head and Neck Surgery (2016) 27, 129-135
- Four cystic parathyroid adenomas in a 71-year-old man. Bann DV, Goldenberg D. Ear Nose Throat J. 2016 Jan;95(1):21-2. No abstract available. PMID: 26829681
- Comparison of SPECT/CT and planar MIBI in terms of operating time and cost in the surgical management of primary hyperparathyroidism. Setabutr D, Vakharia K, Nogan SJ, Kamel GN, Allen T, Saunders BD, Goldenberg D. Ear Nose Throat J. 2015 Oct-Nov;94(10-11):448-52.
- Parathyroid localization using 4D-computed tomography. Bann DV, Zacharia T, Goldenberg D, Goyal N. Ear Nose Throat J. 2015 Apr-May;94(4-5):E55-7. No abstract available.
- PMID: Radiographic evaluation of non-localizing parathyroid adenomas. Payne SJ, Smucker JE, Bruno MA, Winner LS, Saunders BD, Goldenberg D. Am J Otolaryngol. 2015 Mar-Apr;36(2):217-22. doi: 10.1016/j.amjoto.2014.10.036.
- PMID: Parathyroid adenoma in a woman with secondary hyperparathyroidism. Bann DV, Goyal N, Goldenberg D. Ear Nose Throat J. 2014 Apr-May;93(4-5):158, 160. No abstract available.
- Trends in intraoperative neural monitoring for thyroid and parathyroid surgery amongst otolaryngologists and general surgeons. Ho Y, Carr MM, Goldenberg D. Eur Arch Otorhinolaryngol. 2013 Sep;270(9):2525-30. doi: 10.1007/s00405-013-2359-6. PMID
National and international Presentations
- Early neurocognitive improvements following parathyroidectomy for primary hyperparathyroidism. Shah-Becker, S., Derr, J., Oberman, B., Baker, A., Saunders, B., Carr, M., Goldenberg, D. (2016, September). AAO-HNS annual meeting, San Diego, CA April 2017
- The utility of intraoperative PTH in the setting of pre-operative imaging localization and concordant operative findings. Shah-Becker, S., Goldenberg, D. AHNS at COSM, San Diego, CA. April 2017
- Early improvements in mood and sleep following parathyroidectomy for primary hyperparathyroidism. Shah-Becker, S., Derr, J., Saunders, B., Oberman, B. ,Baker, A., Carr, M., Goldenberg, D. (2016 Jul). AHNS International Meeting, Seattle, WA 2015
- 4D-CT scoring and protocol optimization of parathyroid adenomas. Challenging diagnosis made simple. Shah-Becker, S., Zacharia, T., Kalapos, P., Schaefer E., Moser K., Goldenberg, D. (2015, April). COSM Annual Meeting; Boston, MA 2014
Imaging modalities in parathyroid surgery
Until recently, the planar MIBI (or sestamibi) scan was the best available imaging technique for preoperative identification of a parathyroid adenoma (tumor). The limitations of this scan are that it only shows "front to back" flat images limiting the surgeon’s ability to locate the parathyroid adenoma. Additionally an enlarged thyroid gland, which sits in front of the parathyroid, may obscure the parathyroid adenoma. To date, many parathyroid surgeons still use this sestamibi scanning (Figure 1). In many modern parathyroid practices Hybrid imaging (combining two imaging techniques) has increasingly been accepted as a modality of choice for the evaluating parathyroid adenomas.
SPECT/CT (single photon emission tomography/computed tomography) in which a 3D MIBI scan and CT scan are superimposed and then fused. This provides superior preoperative visualization of the parathyroid adenoma from all angles (Figure 2). This is the technique we use here at Penn State Hershey.
Multiphase CT has become a popular study for preoperative parathyroid localization given the high accuracy.
The “4D-CT” scan was originally described using 4 separate images phases, 1 noncontrast and 3 post contrast. Most recommend using a 3-phase technique to reduce the radiation dose. The first noncontrast images can be helpful to distinguish adenomas from the intrinsically dense iodine-rich thyroid gland, while the early and delayed postcontrast imaging highlight the hypervascular nature of adenomas and their characteristic early washout. Most multiphase 4D-CT techniques report a sensitivity and specificity exceeding 90% (Figure 3).
Vocal Cords are Protected from Damage During the MIRP Procedure
Many patients have been informed the risk of parathyroid surgery (even MIRP) is damage to the nerve that goes to the vocal cords (voice box). This is called the recurrent laryngeal nerve. Should this nerve be damaged, the patient may suffer from temporary or permanent hoarseness. To complicate matters, often the parathyroid adenoma is found directly adjacent to this nerve. Surgical expertise in identifying and avoiding the recurrent laryngeal nerve is key.
Another tool we use to enhance patient safety is intra-operative neural monitoring (IONM). IONM allows the surgeon to monitor the activity of the recurrent laryngeal nerve during surgery and help keep it safe.
Your surgeon may view your vocal cords with a small camera before and after surgery.