0:02

Hello and welcome to Noon Conference, hosted by modality

0:06

Noon Conference connects the global radiology community

0:08

through free live educational webinars that are accessible

0:12

for all and is an opportunity

0:13

to learn alongside top radiologists from around the world.

0:16

You can access a recording of today's conference

0:18

and previous noon conferences by creating a free account.

0:22

Today we're honored to welcome Dr.

0:24

Alka Singal back to this noon conference stage

0:26

for a lecture entitled Parathyroid Ultrasound, how

0:30

to Identify and Differentiate From Other Neck Pathology.

0:34

Dr. Singal is associate director

0:35

of radiology at Madonna Med City Hospital Deli, and CR India

0:40

and has over 28 years of experience in radiology.

0:43

She's done great work on ultrasound localizations

0:45

of parathyroids with over 1000 ultrasound

0:48

parathyroid localizations.

0:50

She's authored several publications

0:52

and talks for leading national and international conferences

0:55

and is the author of Atlas of Parathyroid ultrasound.

0:59

At the end of the lecture, please join her in a q

1:01

and A session where she will address questions you

1:03

may have on today's topic.

1:05

Please remember to use that q

1:06

and a feature to submit your questions so we can get to

1:08

as many as we can before our time is up.

1:11

With that, we're ready to begin today's lecture. Dr.

1:13

Singal, please take it from here.

1:15

Thank you so much for the wonderful, warm welcome.

1:18

I'm truly very excited

1:20

and barath her is truly very close to my heart.

1:24

It's my fashion area

1:25

and I'm so, so excited to share it all with you.

1:28

Thank you. Alright, thank you so much everyone,

1:32

and thank you so much Dr. David

1:34

and entire team of MRI online

1:37

and thank you everyone for your wonderful kind gestures

1:42

and excitement that you put in in all the talks.

1:44

Thank you so much. So to begin with, we are today going

1:49

to talk about the ultrasound, the bladder thyroids.

1:52

Can we localized on ultrasound?

1:54

I've heard many of my colleagues say, oh,

1:56

I haven't even seen a parathyroid once.

1:59

Oh, now I'm beginning to see, oh,

2:02

I can see it with confidence.

2:04

So depending upon which

2:06

place are you in your journey

2:09

of discovering the parathyroid and ultrasound.

2:12

So you can always level up and go forwards.

2:16

So honestly, ultrasound is an immensely

2:21

very user friendly and a very powerful modality

2:24

because it's so dynamic.

2:26

You can really maneuver around

2:28

and in real time, get all the answers that you're seeking,

2:32

talk to the patient, assess the clinical situation,

2:36

and really come to a wonderful diagnosis.

2:39

So ultrasound is my favorite

2:41

and localizing parathyroids, it's like, oh,

2:44

where are you hiding?

2:45

Let me find you. It's like a game that I'm playing

2:47

with the parathyroids and it's really a eureka moment

2:51

for me when I really find those better thyroids.

2:54

So, and I'm here to share all the tips and the tricks

2:57

and the secrets that I apply to find them

3:00

and hopefully that will contribute in your practices

3:04

and transform them towards better healthcare for all.

3:08

So to begin with,

3:11

why do we approach the better habits and ultrasound?

3:13

Why is the patient sent to you in the first place?

3:16

Because ultrasound is not really for thyroid nodules.

3:20

We are doing a thyroid scoring.

3:21

We are characterizing whether it's benign IC then,

3:24

but parathyroid nodules aren't normally seen.

3:28

That's the point number one.

3:30

So unless diseased, I normally do not see a parathyroid.

3:35

So that's the thing.

3:36

So thyroid we normally see,

3:39

but parathyroid we don't normally see.

3:42

That's a very important,

3:43

many times I do see discrepant reports which says normal

3:47

parathyroids or foreseen, et cetera, et cetera.

3:51

When they're deceased, when they are enlarged,

3:53

when they're pathological, then only you see them.

3:56

Normal sizes are small, maybe in times to come.

3:59

But for now, that's the thing.

4:01

So clinically patient is PHPT,

4:06

which is primary hyperparathyroidism

4:08

or secondary hyperparathyroidism

4:10

or tertiary hyperthyroidism.

4:11

There is an elevated PTH,

4:14

there is an elevated parathyroid hormone,

4:16

there is a derangement of the serum calcium levels

4:20

and obviously I'm moving on with an assumption

4:22

that we all have an understanding of the calcium

4:26

hyperthyroid metabolism, vitamin D renal function base,

4:31

understand the pathophysiology where calcium elevates

4:34

because obviously I've done a lot

4:37

of deep diving in writing the textbook

4:39

of parathyroid ultrasound.

4:41

So endocrine survey has been done.

4:44

The patient is clinically diagnosed with hyperparathyroidism

4:47

and there is a system EB positive case of hyperthyroidism.

4:52

So nuclear medicine scan,

4:54

which is a technician 99 scan a little bit about it.

4:58

So there's a technician contrast that is given

5:01

and you take images after 30 minutes

5:03

and another delayed image after two hours.

5:06

So initially the contrast is taken up

5:09

by all the areas which have high mitochondrial activity,

5:12

which includes parathyroids and thyroid, follicular adeno,

5:18

and other ALI glands and other areas.

5:20

However, on delayed scan, there's a washout that happens,

5:25

but certain areas that retain the contrast,

5:29

which is uh uh, the parathyroid adenomas

5:32

or even thyroid follicular adenomas that are imaged.

5:36

So with this, and then we do expect CT to actually see

5:41

where it is in the three damaged cell plane

5:43

and understand the location of the,

5:48

after this has been done or before this has been done.

5:54

Then we come to the ultrasound.

5:56

So we have to localize the parathyroid nodule

5:58

and system may be positive cases, VA parathyroidism, we have

6:02

to do S exact nodule mapping.

6:04

So once there is a nodule, we know

6:06

that the outcome is probably a surgery to take it out

6:09

to cure the patient of the symptoms of PHPT.

6:12

So, and it's sacked mapping in three dimensional pain

6:15

to give the best guidance to the surgeon.

6:18

And there are cases when there is a clinical PHPT, right?

6:21

But this system maybe is not localizing.

6:24

We will come to those cases

6:25

because when there is a very positive of the mitochondria,

6:29

uh, then if it's predominantly cystic lesion,

6:33

then it doesn't show up on that.

6:35

And however ultrasound can still detect it.

6:38

So see there is a great potential for it.

6:41

But yes, ultrasound is limited in mediastinal para, uh,

6:44

parathyroid adenomas where system E can light them up.

6:48

And then of course we may need a 40 CT

6:51

and additional no nodules not detected on other emit.

6:54

So it'll also evaluate the thyroid, the parathyroid,

6:57

and sometimes they may be dual parathyroid

7:00

that we do not know, but those will also be detected on the

7:04

scan but not on the thyroid.

7:06

Characterize the nodule, the characters.

7:08

Sometimes it may be very heterogeneous

7:10

as we look at into the cases, whether it's a carcinoma

7:13

because carcinoma

7:15

and adenoma, it's a histopathological diagnosis.

7:18

But the ultrasound features the appearance of it.

7:21

It tells us that where are we and what are we looking at?

7:24

Unless it's a clinical, there may be a clinical suspicion

7:28

by significantly elevated serum calcium

7:30

and significantly elevated serum PH

7:33

as we will look into the cases.

7:35

And of course associated thyroid

7:37

knotty rules, the background.

7:38

Next, complete evaluation of the adjacent

7:41

and neck structures can be done.

7:42

Additional benefits. Key questions.

7:45

Why is the patient here for you?

7:48

What does the surgeon need to know

7:51

and what is the role of bi clinical parameters

7:54

and correlation with the other imaging and what needs?

7:57

So we always, I, what I do is I look at the prescription,

8:02

I do my test and then I, I take the reports,

8:06

but I do my survey and my test and my ultrasound scan.

8:09

And then after I've done,

8:11

then I also correlate with the all the other imaging.

8:13

So I do an unbiased examination and do compare

8:16

and if I need to relook, I relook

8:18

before I send the patient out.

8:20

So we all know what is the serum calcium level.

8:26

Please write in the chat or in the q

8:28

and a if you all know that, I assume you all know that I,

8:32

I'm also assuming that you all know

8:33

what is a serum normal parathyroid hormone level.

8:37

And I would be very happy for you to write in the chat

8:40

or in the q and a so that we have an interactive session.

8:43

Because when we are looking for a elevated serum beta at cg,

8:48

the first thing that we are looking at, uh, for,

8:51

for an ectopic gestational sat,

8:53

we look at the serum beta at CT levels, right?

8:56

So normal parathyroid, we don't see to look for it.

9:00

We must need to have a situation where we can find

9:03

to understand that situation.

9:05

We need to understand that by clinical parameters.

9:08

So that's where the patterns come.

9:09

And of course on a 2D ultrasound,

9:11

we are doing a 3D localization.

9:14

I do, and it's that mapping as to where it's located.

9:17

As I will explain you on this image.

9:19

So assuming that's theus and that's the thyroid parenchyma

9:24

and is said normal, that's the common carotid

9:26

artery and that's a better thyroid.

9:28

So I'm going to explain that.

9:29

Okay, this is located in the esophagal groove,

9:33

little bit lateral to the esophagus,

9:35

and then it's very closely abutting the spine.

9:38

It's located medial to the carotid, it's located presti

9:41

or medial to the carotid and so on.

9:45

I will look at all these various findings

9:47

and I will actually give my surgeon in a very clear idea

9:50

that look, it's in the superficial plane,

9:52

it's in the deep plane,

9:54

and how deep, uh, the surgeon needs to give an incision,

9:57

is it tipping deep into the posterior neck?

10:00

So all those findings help the surgeon plan whether they can

10:03

go for a focused parathyroidectomy

10:06

or they need to plan it more extensively, right?

10:10

So now where are the parathyroid lines located?

10:16

We cannot, I mean my work area is complete.

10:20

Basically I, I do scan all the area from the angle

10:23

of jaw lying to the external angle to the clavicles to

10:28

wherever I can put my transducer in.

10:31

But normally the parathyroids, they are parathyroid means

10:35

around the thyroid.

10:37

So the superiors are normally situated not behind the upper,

10:42

but I normally find them behind the mid hole, kind

10:44

of slightly towards the upper side.

10:46

But however, if the gland is significantly enlarged,

10:50

it can enlarge in any direction.

10:53

The pathology, if it's a cystic component,

10:55

it can really dig down.

10:56

So then you can see it very rarely to the project

11:00

beyond the superior pole.

11:01

They often tend to grow down it gravity

11:04

or whatever is the reason.

11:06

That's how they dip into the neck and you find them.

11:10

So superiors are here behind the mid pole

11:12

and the inferiors are usually in a one centimeter radius

11:16

around the lower pole.

11:18

Okay? So usually inferior can be posterior,

11:21

can be posterior medial kind of a situation.

11:24

Now the key factor is the vascularity.

11:29

So both of them are normally supplied by the uh,

11:33

inferior thyroid artery, which is a branch of the thro

11:37

of the thro cervical trunk.

11:39

And it goes to supply both the superior parathyroid

11:43

and the imperial bether.

11:45

Now the key factor to note is

11:46

that this vessel can you see a little forking pattern.

11:50

So it is a forking pattern of the vessel as it branches.

11:55

So the vessel comes and it just fos and branches.

11:58

See if we can just feel that folk here.

12:01

A polar feeding vessel that is forking

12:03

or branching at the pole is very characteristic

12:07

and very suggestive of a better, if I can recognize

12:11

that vascular signature, it's really, really very, very

12:16

reassuring that I'm very confident of my osis.

12:20

Okay, so the arterial supply is usually from the impeded

12:23

thyroid artery as I've just explained.

12:26

So that's the, uh, thyroidic trunk which is giving

12:29

of the inferior thyroid artery that goes to,

12:32

or it can be from the anastomosis between the superior

12:35

and the imper thyroid artery or from the thyroid, Emma

12:38

or the superior artery.

12:41

So like a set thyroidic trunk skiing out the,

12:44

the inferior thyroid artery, which is going

12:47

and branching at the pole and like classic impedance.

12:51

We will see how this translates to our ultrasound imaging

12:55

and that really, really is very rewarding

12:57

to give a very confident diagnosis.

13:00

So this is the understanding of the location of the thyroid

13:03

and the vascularity.

13:04

So you can have from the thyroid survival trunk going

13:08

to here or you can have from the anastos.

13:12

Another important point to understand in the location,

13:15

where are you looking for them is understand the embryology.

13:21

So radiology is all about anatomy

13:23

and anatomy To understand anatomy, we understand embryology,

13:28

where did we pump from our root, our source.

13:31

So the source, where is,

13:33

where did the parathyroids come from?

13:34

They originally originated high up in the neck.

13:38

So from the, uh, from the uh, panal pouch.

13:43

So the superiors the normally uh, uh, are

13:48

uh, grow with the thyroid

13:51

and they are often found a little higher up

13:54

or they may be, if at all there is an inadequate descent,

13:57

they may be trapped in within the thyroid.

13:59

Heim inferiors normally developed along with the thymus.

14:05

So they often go down and descent

14:07

and if at all they're ectopic,

14:08

they may be found along the thymic tract.

14:12

So thymic tract would be really an imaginary line

14:15

as if you're drawing from the lower pole

14:17

of the thyroid towards the stern angle where the thymus is.

14:22

So if you can't find the parathyroid, just

14:25

where you assume they would be.

14:28

So you would obviously look for the superior parathyroids

14:31

or maybe inferior parathyroids anywhere high up in the neck

14:34

where they have failed to dissent

14:36

or if they have diss descended beyond

14:39

where they were supposed to be normally stationed, you would

14:44

go beyond the lower hole towards the sternal angle.

14:47

And beyond that, of course we need a CT to see for media,

14:50

staal parathyroid, it's simple, right?

14:53

Let's understand how this happens. Okay? Right?

14:57

So a basic understanding of the calcium metabolism is the,

15:02

is well known to all of us.

15:05

Now with this understanding why we need to look for them,

15:10

where we need to look at them.

15:12

Now how do we look for them?

15:15

How, what are the tools that we are going to use?

15:17

We are going to use a high frequency test transducer.

15:21

We are going to use a transducer.

15:23

If there is a large multi modular coter, we may need

15:26

to use a curry transducer to get the depth

15:28

of penetration, right?

15:30

Sometimes to look into the sternal angle,

15:32

I use a little hockey stick probe

15:34

to look along the clavicle margins to look along the angle

15:38

of jaw and other spaces so that where I can have,

15:41

make a nice contact with the skin so that I can

15:45

evaluate if at all, if that's not available

15:48

or even if you want you can use the transfer angle pro,

15:51

which just got a little small round footprint

15:54

so you can make a nice contact with the sternal angle

15:56

and really B weight that area.

15:58

So these little tips really improve the diagnostic outcome

16:03

and is very rewarding.

16:06

So to begin with the seven to 14 linear hertz transducer

16:10

and then of course we'll scan, begin with the survey scan

16:14

and scan thoroughly

16:15

through the thyroids in the area around the thyroid.

16:18

And of course then lastly you will scan the time,

16:21

time tract look for topic scan up to the angle of the jaw.

16:26

Okay, we'll look at more in the cases as we come.

16:30

So typical parathyroid looks homogeneous,

16:35

um, avoid uh uh not you,

16:39

which has great vascularity on color doppler,

16:42

which we will look in the next image.

16:44

And now this picture is actually well contrasted when you

16:48

have a very nice normal thyroid chy.

16:52

So I could do an advanced session maybe for IC physicians

16:56

where you have a, like a, you know, very hypo thyroid,

17:02

really a multinodular thyroid, really a neck full

17:05

of lymph nodes like I've found parathyroid aism dose.

17:09

So those are the challenging cases,

17:11

but to understand, let's begin with the simplest scenario.

17:14

So we actually get to know them

17:17

and then we find them in challenging situations as well.

17:21

So they tend to be homogeneously hyper going

17:24

to the overline thyroid gland

17:26

and they are discrete oval

17:30

and located posterior to the thyroid gland.

17:32

And often you can identify the capsule of the thyroid.

17:37

The a thin echogenic line

17:39

that separates thyroid gland from the enlarged parathyroid

17:43

and larger A are more likely to wonderful cystic changes

17:48

ations calcifications.

17:51

So those are the pointers also that you need to add

17:55

to your reporting

17:56

because a little solid component may just show up on

18:01

system, maybe scan the Dr. May think, okay,

18:03

maybe I'm looking at so andSo size lesion,

18:07

if there is a LA little solid component

18:10

and a large cystic component that is there,

18:13

only ultrasound will find it

18:15

unless there's any other imaging done.

18:18

So extent of all that information must be given

18:21

to the physician now.

18:25

So we talked about all those things.

18:27

Now let's, this is a static image where we have a

18:33

thyroid parenchyma.

18:34

This is the skin subcutaneous fat strap muscles

18:38

and that's the capsule, ant capsule of the thyroid,

18:41

that's the prestig, the spine

18:42

and that hyper area is the parathyroid.

18:46

And that's a very nice echogenic capsule seal

18:49

that I can really, well very well identify.

18:52

Now look at the video clip.

18:54

So I hope you are all able to identify that

18:58

that's the vessel that's coming.

18:59

That's the ed thyroid artery

19:01

that's in the transverse coming from the thyroid IAL trunk

19:05

that was the inferior thyroid artery.

19:06

And look how it's beautifully, really beautifully branching

19:11

and poking the pattern that I was trying

19:13

to describe in anatomy slides.

19:15

We can really see that on ultrasound.

19:18

So if you see this pattern, it is very, very classic

19:22

of the parathyroid seeing this.

19:25

I do not even need to think beyond that,

19:27

whether it's a lymph node or whether it's a thyroid.

19:30

Not huge. I would say some,

19:32

many times I have an incidental diagnosis.

19:34

A patient's not had a calcium done,

19:36

not had a parathyroid done,

19:37

but I really see I just tell them, please go

19:40

and get your calcium and PTH done.

19:42

There has to be a parathyroid.

19:44

Do you know what I'm looking at?

19:45

So look at the uh, clip, uh,

19:49

one more time just to memorize this vascular signature

19:53

because that's the real crux of your diagnosis.

19:56

Once you identify this, this, this image

20:01

is actually replicated even in intra thyroidal parathyroids

20:05

and whether they are located anywhere,

20:07

whether they're located at the angle of jaw

20:09

or whether they're located in the external angle.

20:13

Once you recognize this, it becomes very simple

20:16

and very easy to identify with confidence.

20:20

Okay, so moving on to the next, uh, they are,

20:25

their majority are being shaped.

20:28

What are the doppler features like we just discussed?

20:30

They are hypervascular lesions.

20:32

There's an characteristic centric vascularity

20:35

arc limb vascularity and the polar feeding vessel.

20:39

So they're hypervascular,

20:40

it just in thi parenchyma may also show some

20:43

increased vascularity.

20:44

You can see the polar feeding vessel

20:47

and uh, that's another parathyroid.

20:50

So you can see the polar feeding vessel that's like, so

20:54

that's a real time, that's a great clip

20:56

that is showing the thyroid parenchyma

20:59

and the hyper lower pole.

21:01

And see how the moment you put the color on,

21:03

you can see the arc limb vascularity

21:06

and you can see the classic polar feeding vessel sign.

21:09

This is very, very suggestive and very convincing.

21:15

Okay? And again, so that's a zoomed image of the same.

21:19

You can identify this very clearly and very nicely.

21:26

Mm-hmm

21:29

Okay, right.

21:32

These are some static images. Uh, this is a pen view.

21:36

This just, it looks beautiful

21:38

and it's nice to communicate to the surgeon.

21:41

So where the hyperthyroid is located, nice,

21:44

well defined homogenous, avoid,

21:47

and that's a nice normal thyroid parenchyma.

21:51

That's a nice per thyroid.

21:53

That's the per thyroid, that's the common carotid.

21:56

That's again the vascularity and all these things.

21:58

That's again, a little bit non homogeneous per uh,

22:02

thyroid parenchyma here.

22:03

So see the contrast goes down.

22:05

Sometimes you can have a very hyper IC para

22:09

thyroid chy in itself.

22:11

Those are the situations when it really comes

22:14

to do in it's bird scan.

22:16

So again, here you see the characteristic

22:19

hoking of the blood vessel.

22:21

Now looking beyond the typical scenarios,

22:25

the lesions can be large lesions can have uh,

22:29

uh, cystic changes.

22:30

So here's a larger parathyroid.

22:33

Some areas show some cystic change

22:35

and again, significant vascularity, some little,

22:38

little cystic changes that you can identify.

22:40

Look, this is a superior parathyroid again,

22:43

so if you see the blood vessel,

22:45

so it's like the vessel is just coming

22:46

and it's like kind of forking here and it's like going up.

22:51

So inferior parathyroids

22:53

and superior parathyroids, the vessels going like that up,

22:56

you can identify them.

22:57

Sometimes that really helps you conclude in no,

22:59

that is located behind the mid pole, whether it's a superior

23:03

or an inferior depending I perhaps maybe

23:06

with the orientation of the blood vessel.

23:09

So again, that's uh, uh, parathyroid, that's uh,

23:12

that's the thyroid parenchyma

23:14

and that's a parathyroid that you can identify.

23:18

Okay. Alright, so moving on to the next thing,

23:23

much more larger parathyroids.

23:28

I'm sure you can see that

23:29

because it's been labeled

23:30

as a large elongated superior parathyroid.

23:33

And the reason why I've included this case here,

23:35

because this case was initially western on ultrasound

23:38

imaging and it was sent to me again for a second opinion

23:41

where I said there's a large STA,

23:44

which is just sleeping behind the thyroid.

23:47

So you know what they can be mistaken

23:49

for strap muscles itself or anteriorly or posteriorly

23:53

or just the neck, uh, uh,

23:55

connective tissues and other things.

23:58

So be aware of that.

24:01

And your guide is the vascular signature.

24:05

Very characteristics.

24:06

See again, there's a forking, kind of a vascular signature

24:10

that is very well identified vascular vascularity

24:14

and the forking of the blood vessel.

24:16

So this pattern clearly says that that is the better.

24:19

Of course the clinically the patient has elevated serum

24:22

calcium and PTH

24:24

and there is a large parathyroid which is located

24:27

behind the thyroid.

24:30

Now here's another interesting case.

24:31

This was another case

24:33

that was actually a missed parathyroid.

24:36

Why dunno system maybe is got,

24:40

uh, this is a delayed film which is showing retention all

24:44

along the right side.

24:46

Now there's a huge parathyroid, which was actually reported

24:50

as a normal thyroid tissue.

24:52

Why this patient is actually on thyroid medication

24:55

for about 25 years.

24:56

The thyroid parent car itself is just this very little area

24:59

that you can see here, which is almost all truken and small.

25:04

And this was all the parathyroid

25:06

that was sleeping here behind it.

25:08

So we have to be aware of those scenarios.

25:11

Again, a larger perha, which appeared

25:13

to be like kind of a bope.

25:15

And this is only the little bit

25:16

of the thyroid parenchyma again, a patient with

25:20

hypothyroidism on, on thyroid medication for many,

25:23

many years, 20, 25 years or more.

25:26

And we have a large parathyroid, which is here mistaken

25:30

for the thyroid gland itself.

25:33

Interesting. So like I said, what other changes can you see?

25:37

You can see some calcifications. Second.

25:43

Okay, nevermind.

25:45

So we have uh, uh, sep septations.

25:49

You can see cystic changes, you can see vascularity,

25:52

you can see a small cystic change

25:55

and you can see a large cystic change.

25:58

So this is a small cystic change, a little bit of pan view

26:01

to show the carotid, the thyroid parenchyma

26:04

and the parathyroid and the cystic change.

26:06

And this has got some soft tissue component

26:09

and majority component is cystic.

26:11

So those are the areas that we really, really have

26:13

to be very careful in labeling the diagnosis.

26:17

Another parathyroid,

26:18

which has got a significant cystic component.

26:21

And this patient was very interesting

26:23

because it just showed up a very small area

26:26

of color uptake here.

26:29

A very small, you know, a subtle, uh,

26:33

positivity on system and look at this

26:36

and you all can also, can you appreciate

26:38

that this is the bones in the spine.

26:40

Can you also appreciate that this is actually dipping deep

26:43

into the posterior neck?

26:44

And I remember my surgeon calling me

26:46

and telling me it was a very challenging surgery.

26:48

This, you know what, they have to take it out in total

26:51

because they cannot have a thyroid storm storm on the

26:54

table, on the hormone.

26:56

So, uh, this is, uh, the thyroid per,

27:00

and that's the parathyroid with the vascularity here

27:03

and tipping deep into the procedure neck.

27:06

So those are the things again, uh, large cystic parathyroid,

27:11

just a subtle retention of the tracer on ssta maybe.

27:14

And this has got some layering, so maybe

27:17

with subtle some hemorrhage or something.

27:19

And just a marginal soft tissue component

27:22

that light up on system.

27:24

Majority of the component is cystic and with some every

27:27

or content as well.

27:29

Now. So we've seen large,

27:33

we've seen different scenarios, uh, diff different sizes,

27:36

atypical appearances, not different

27:39

clinical scenarios come in front of us.

27:42

What are the different clinical scenarios?

27:43

One is the primary PHPD, one is the secondary PHPD.

27:47

And what is the tertiary PHPD? What is primary?

27:50

So the primary is vendor parathyroid.

27:53

It's ADM itself as a primary source

27:55

of all the metabolic expenses.

27:58

Secondary when there is a vitamin D deficiency commonly

28:01

or a renal failure that leads to the hormonal imbalance

28:06

and, uh, leads to, uh, hyperparathyroidism.

28:10

Third, when the para, when the uh, uh, the cause

28:15

that caused the secondary hypertension has already been

28:17

treated and managed as in cases of post renal transplant

28:22

that has been managed, but still there is a persistent,

28:25

uh, hyperparathyroidism.

28:27

Those are tertiary hyperparathyroidism.

28:30

So in primary, usually you see a single nodular disease.

28:33

In secondary you may see multiple clain management.

28:36

And in tertiary you may see again multiple plant management.

28:40

So this is important for us to know and

28:42

accordingly look for more.

28:45

This is how we've always learned in radiology, in admin,

28:49

medical devices, uh, medical studies.

28:51

So we, we see one, we don't just stop there, we have to

28:55

ensure that we have looked completely and thoroughly.

28:59

Now I'm just going to take a, a little bit of the journey

29:03

through some interesting cases.

29:06

So easy cases, we've already see

29:09

topic cases we will see some

29:11

and challenging cases where sister was negative,

29:14

still the patients, what they go through.

29:18

I mean, in over these years I've like known like the subtle

29:22

symptoms that the patients go through, subtle fatigue,

29:25

mental, uh, symptoms and various others.

29:29

And when the, uh, this all is corrected, they feel

29:34

as if all cloud or weight is lifted over them.

29:37

You talk to them, it's like, it's like a beautiful,

29:40

they can feel life after that.

29:43

It's very rewarding.

29:45

And of course, deep posterior not use multiple

29:47

birth thyroids and rare cases.

29:48

Let's have a look. So this is a little bit about the data

29:51

that I published way back in 2000

29:54

and uh, 19 at the European,

29:59

uh, ECR and then it was finally published in the Bull

30:03

Journal of Endocrine Surgery.

30:05

And so, uh,

30:09

majority you see single, huh?

30:12

So, uh, and then you have ectopic

30:16

and, uh, multiple nodules in more than, uh,

30:20

in 10% cases.

30:22

And of the solitary in adenomas, 83% are just thyroid

30:27

and the remaining 16% are in ectopic.

30:30

So ectopic is significant 15%.

30:33

And of course you also supernumerary parathyroids,

30:36

which often see men in Rome and other cases

30:38

or recurrent PHPs and other scenarios.

30:41

Okay, so like I explained ectopic parathyroids,

30:46

we had a little bit of understanding of the embryology.

30:49

So where did the origin and where did the descent?

30:51

So we've descended halfway

30:54

or the descended more than what they have to, that leads

30:57

to the various locations of the parathyroid.

31:00

So the normal location is close to the posterior surface

31:02

of the thyroid as we discussed.

31:04

So they could be scented or over descented

31:08

or trapped during the descent leading

31:10

to intra thyroid and parathyroid.

31:13

Okay? So they are formed with the, the high hys

31:17

and the thyroid and

31:18

accordingly with the descent unde descended,

31:22

you can find them high cervical parathyroids

31:25

or intra thyroidal parathyroids

31:28

or you can find them in the tres eal groove

31:31

or along the th tract or in the media style,

31:36

or you can find them in the carotid sheet.

31:40

Okay, so majority, uh, superior para are usually

31:45

behind the upper and the mid pole like I discussed.

31:48

And less often behind the upper pole

31:51

or in the esophagal group, majority

31:54

of the imper parathyroids are around the lower pole

31:57

or they could be chest thyroidal or intra thic

32:01

or ectopic in the mediastinum

32:03

or the, uh, paraesophageal areas.

32:07

So this is the data for what I localized, so which matched

32:12

with the metadata that has been published in the location.

32:15

So mainly, uh, the

32:19

localization was along the, uh,

32:22

inferior in the upper pole was matching the data.

32:25

Now sensitivity system maybe was positive in localizing the

32:29

nodule in 84% cases

32:32

and of the localized system may be nots, 82% were uh, true

32:36

and 3% were false.

32:38

And ultrasound localized in 96% cases.

32:40

So not used localized

32:41

by ultrasound were two in 99% was in 1%.

32:45

Ultrasound localized the nodules in system e negative cases

32:49

in two 12% of patients.

32:51

So there's a great yield over

32:53

and above the system E where it really,

32:55

and it also many times it's ruled out false positives,

32:59

false, its negatives as well.

33:00

So we will look at it in the cases.

33:03

Okay, so what is the role of system E?

33:06

Of course it is the primary investigation and uh,

33:10

but then, uh, we, we have

33:11

to remember there is a system e negative hyperparathyroidism

33:15

and over diagnosis of system may primarily in cases

33:18

of poly adenomas.

33:20

So that's why we need another imaging ultrasound

33:24

or CT must be done.

33:26

Okay, so topic along the th of tract by definition,

33:31

if the parathyroid is not like along,

33:33

just along the capsule, if there's any distance

33:36

between the time it becomes an ectopic.

33:37

So there's like about five millimeters below the lower pole.

33:41

Okay, now this was interesting, a patient who was booked in

33:44

for a routine hysterectomy and had elevated calcium

33:48

and PT edge came to me for an ultrasound

33:51

and I looked around the thyroid, uh, didn't see anything,

33:54

but then I move my probe up,

33:56

up near the submandibular just a little bit

33:59

to the right of sub mandibular.

34:00

I see a nice well-defined hypo echoic.

34:03

So just lateral to the submandibular,

34:06

I see a nice well-defined hypo echoic rounded, uh, area.

34:10

And see this is a subular, this is the parathyroid,

34:13

that's the carotid vessels over there, uh,

34:16

beyond the bifurcation.

34:18

And look at the color LAR features. Wow.

34:22

So see the beautiful art that you can appreciate.

34:25

There's not a lymph node, there's no hilum here,

34:26

there's no vascularity.

34:29

So it's very classic.

34:30

And this was published in the Journal

34:32

of Head and Neck Physicians.

34:34

And when I went to see my, meet my CT

34:37

colleagues in the nuclear medicine

34:39

and they were looking at it, oh, there it is sitting here.

34:43

So beautiful correlation. Very nice.

34:45

So a topic in the carotid sheet,

34:47

you can find topic in the paraesophageal groove you can

34:51

find on the side.

34:52

You can see by the oph a topic in the media sternum,

34:56

like this was another challenging case.

34:58

She was anesthetic challenge for an anesthesia for some, uh,

35:02

was referred to IR for uh, like uh,

35:06

P-P-H-P-D was very high.

35:08

Uh, PTH was 4,000 3, 3 6 I think it was.

35:12

Um, uh, originally higher

35:17

or no, the what hap

35:19

what was there was multiple lymph nodes there.

35:21

In the midst of that I did localize

35:23

that this there is a parathyroid.

35:26

The patient had the RFA done and the levels dropped down,

35:30

but then still the pH uh, parathyroid hormone was elevated.

35:33

And then after that they did the system AB

35:36

to find there another one in the media.

35:40

This was another interesting case

35:42

of an ectopic intra thyroidal parathyroid.

35:46

So here is an 80-year-old male diagnosed

35:48

with PHPT hypertension hyperthyroidism system may be saying

35:52

in showing increased uptake at the upper

35:55

aspect of the right load.

35:56

Right now what do we see on ultrasound? So that's it.

36:00

We don't see anything outside the thyroid parenchyma.

36:03

We only see a thyroid, not U appearing area here.

36:08

We assume it's a thyroid, not U right,

36:11

but it does show characteristic vascularity pattern

36:16

and basis of the clinical findings and situation.

36:20

It patient was taken up for surgery

36:22

and this did come up as a para, uh, parathyroid surrounded

36:27

by thyroid confirmed as an intra thyroidal parathyroid oma.

36:32

However, it is not always the same.

36:36

This case was an eye-opener and a learning for me

36:38

and really inspired me to work more

36:41

and more, uh, you know, um, into the journey of this, uh,

36:46

parathyroid work.

36:47

So this patient was referred for

36:50

of course primary PHPT female

36:52

with multiple surgeries called a cystectomy pancreatitis,

36:56

ulcerative colitis, primary hyper aldosterone

36:59

and ectomy query men.

37:02

So multiple syndrome, multiple surgeries

37:04

and multiple episodes of uh, uh, clinical attacks due

37:09

to hyperpara.

37:12

Now ultrasound is showing increased uptake

37:15

in both the lower goals.

37:16

There's more on the right and less on the left, right?

37:19

So it was assumed

37:21

or given a clinical diagnosis

37:23

of right PD para intra thyroidal parathyroid

37:26

and a left inferior intra parathyroid.

37:29

Remember primary seldom uh uh, uh,

37:34

in multi in multiple adenomas primaries,

37:37

usually a solitary parathyroid adenoma.

37:41

So that was the picture. Now this is the ultrasound image.

37:47

Look at this appearance.

37:49

It's a well-defined hyper coic nodular appearance.

37:52

And you see the capsule that's here.

37:54

There's looks like a thyroid follicular adenoma

37:57

against smaller on the left SOAP findings matching the

38:01

picture on the system.

38:02

EB patient was taken up for surgery.

38:06

Both the uh, parathyroids both have protal,

38:11

thyroidectomy was done.

38:13

Patients' PTH did not come to normal post surgery.

38:16

Again, a nuclear medicine test was done right

38:19

and that had like little remnant thyroid tissue.

38:22

And then there was a very classic hypergo nadu

38:26

and which showed an artery vascular clarity

38:28

and it was confirmed on the nuclear medicine

38:31

and PET CT as parathyroid adenoma.

38:34

So what happened was the thyroid not gland was enlarged

38:38

and maybe there was a tiny little parathyroid,

38:40

it was pushed down, it wasn't seen on ultrasound

38:43

and it was a lessons learned.

38:47

With those lessons learned, I learned to follow my instance

38:51

to follow the vascularity pattern, not to be guided

38:54

by the system, maybe not to be guided by

38:57

what they have reported and to do my work independently

39:01

and then match the findings and then review my scan

39:05

and reported a care.

39:07

And this was patient that really won the trust

39:10

of my physicians.

39:11

So this patient has gained clinical PHPD system E is

39:16

reported as you can all see there's an increased RESO uptake

39:19

on the lower part of the left or thyroid

39:22

and which is persisting on the D eight image of a system,

39:26

E diagnosis of left pia parathyroid ioma ultrasound.

39:30

When I do this is the image.

39:32

So these are my images that have been sent to the journal

39:36

of head and neck physicians insertions

39:39

and it has been published.

39:41

So you see an audio which saw some calcifications

39:44

and uh, good vascularity rim vascularity all around.

39:50

So I said that looks like a follicular adenoma basis

39:52

on my experience.

39:53

It doesn't look like a parathyroid at all to me.

39:57

And the interesting part was on the contralateral side,

40:01

on the right side, as I was scanning the,

40:04

I see a homogenous thyroid parenchyma

40:07

and I see a small little hypoechoic module

40:10

behind the lower pole of right thyroid, which showed

40:15

re vascularity and a pool of feeding vessel.

40:17

And I said to my surgeon, to me,

40:20

that looks like the better thyroid.

40:22

Okay, patient was taken up for surgery.

40:25

First Hemi thyroidectomy was done for the left side.

40:30

PTH did not drop.

40:32

And then right side was explored

40:35

and this little parathyroid,

40:37

right inferior parathyroidectomy was performed

40:40

at PTH dropped to normal.

40:42

So they do a PTH level in the table in the room

40:45

to confirm before they close.

40:48

And that was very rewarding.

40:51

Coming to next the size the system may be negative ones,

40:56

the tiny little nodules

40:58

that you think you'll be able to see but you can't see.

41:00

So the challenge is in less than one sitting lesions persist

41:04

is almost always negative.

41:07

So again, this is a clinically confirmed case of PHPT

41:11

where we have a confirmed nodule, which showed very classic

41:15

a cardiovascular as well.

41:17

Another case which shows classic vascularity, another

41:22

case which is ectopic little bit below the lower pole.

41:26

And this was published in the European, uh, journal

41:29

of Radiology case reports.

41:31

Again, this was system EB negative, no retention tracer.

41:35

And we see two parathyroid not used.

41:38

Um, and again, this was another case which showed one

41:43

para thyroid adenoma.

41:45

However, when I did the ultrasound, there were two not used.

41:48

This is one at the lower pole

41:50

and this another behind the mid fold

41:54

coming to the main cases.

41:56

So where you can see multiple nodules.

41:58

And so this is a confirmed case of main one

42:02

where you have multiple parathyroid nodules.

42:04

This is the largest, which is showing up on system ab,

42:07

which is a huge nodule,

42:08

but you also see smaller perdues on the other places.

42:15

Okay, so these are the 1, 2, 3, 4.

42:19

All the four parathyroids are enlarged.

42:22

Coming to this next case, this is a case of brown tumor

42:26

and this is again showed all four parathyroids

42:29

and large classic use of PHPT.

42:32

All the findings that I read in the textbook

42:34

of hyperparathyroidism were all there here for me

42:38

to see for my very eyes.

42:40

So, so this is unusually large brown tumor

42:43

of a mandible in the case

42:44

of secondary hyperparathyroidism mimic tism.

42:47

And this was published in Indian Journal of Nuclear Medicine

42:52

and uh, classic pictures and uh, all the features

42:56

and ultrasound showed all the four parathyroid well

42:59

behind in their normal, uh, thyroid location.

43:05

Now coming to the next role of ultrasound, like I said, to

43:09

make a comment on the character of the nodule,

43:11

whether you're thinking it's going to be a carcinoma

43:13

or a this thing.

43:15

So this patient had I think 14, uh, uh,

43:19

14.5 milligram per deciliter of calcium

43:21

and very high about 5,000, uh, PTH level.

43:27

So look at the thyroid parenchyma nice and homogenous.

43:31

That's the thyroid parenchyma. Look at the per parathyroid.

43:35

It looks like a heterogeneous mass.

43:36

And I'm sure all radiologists working in ultrasound would

43:39

understand that it looks very like an ugly

43:43

or a neoplastic, kind of a malignant kind of a lesion.

43:45

Look at the vascularity pattern on color.

43:48

Very chaotic neovascularization kind of pattern.

43:52

And can you appreciate any capsular clear margins

43:55

between the thyroid parenchyma known?

43:57

So all these findings suggested

43:59

that maybe perhaps we could be looking at

44:01

parathyroid carcinoma.

44:03

And yes, it was adherent to the thyroid.

44:05

The patient was accordingly consulted that we

44:08

who may not be able to separate the parathyroid, we may have

44:11

to remove it along with the thyroid.

44:12

And that was done and it came up as parathyroid carcinoma.

44:17

Another case, which again appeared to me as a variable, uh,

44:21

you know, properly looking at a carcinoma.

44:24

Look at the margins that are joining the capsule

44:26

of the thyroid, not clear cut demarcation.

44:29

This is of course a confirmed case of PHPT with elevated

44:33

13.8 milligram calcium and elevated serum PTH.

44:37

So this was borderline histopathology towards the carcinoma.

44:42

Again, a heterogeneous mask confirmed as neoplasm.

44:47

So most of the patients

44:49

with parathyroid carcinoma have more severe hypercalcemia,

44:53

more severe clinical symptomatology and, um,

44:58

and a heterogeneous mass.

44:59

You can see obviously in all cases we have

45:02

to evaluate the HS and thyroid for any nodules

45:05

or any other pathology that we could evaluate

45:08

and, uh, take care of at the same surgery.

45:11

Right next, this is a rather interesting case

45:15

of a parathyroid cyst.

45:18

So, which was again published in Indian Journal of Radiology

45:21

and Imaging of like, you know, a hyper OID cyst

45:24

and which turned out to be a parathyroid cyst.

45:27

So of course there are limitations of ultrasound imaging.

45:30

Not everything is enabled to ultrasound.

45:32

We do resolve to other imaging modalities, CT 40,

45:37

CT mediastinal.

45:39

So wherever we need to see the con contrast enhancement, uh,

45:44

parathyroid dual appears as a, uh, enhancing nodule

45:49

in the arterial phase and we can localize it.

45:53

So to conclude identification

45:55

and precise localization of enlarged parathyroids

45:59

and the differentiation from thyroid nodules in other neck

46:02

lesions is a key rule of imaging in hyperparathyroidism

46:06

and further PET CT and four CT may be performed

46:11

and uh, really it's very easy

46:13

to differentiate them from other methodologies,

46:16

commonly lymph nodes, tract muscles, anything

46:18

that we've all discussed.

46:19

And to remember, ultrasound is complementary to system

46:23

and offer significant value addition

46:25

by the precise ethical localization characterization

46:29

of the nodule and finding additional nodus,

46:32

giving appropriate, accurate mapping of the nodule

46:36

and combined modalities assessed

46:39

and ultrasound diagnostic sensitivities truly, truly is 99%

46:43

and specificity is 98%.

46:46

Really, really very rewarding results.

46:48

And I really urge you all to use the best tools all

46:52

that you have and go for it.

46:55

And I'm very thankful for the invitation

46:57

to the E-N-Z-H-N-C-S way back in 2016

47:03

when I was blessed to present my, uh, research work

47:07

and really was inspired to meet Dr.

47:10

Hinshaw, Dr. Ashong sha.

47:12

And I really thank them for all the encouragement

47:15

for the work and really inspiring me

47:18

to go further in my journey.

47:19

Thank you to ECR. Thank you Tono, thank you to RSNE.

47:23

Thank you to ISDS.

47:24

Thank you to all the professors, teachers, mentors,

47:28

all the chapters that I was able to write,

47:30

all the opportunities that have come to me

47:33

and thank you to MRI online for giving me an opportunity

47:37

to share all this with you.

47:39

Thank you so much.

47:41

Continuous process of learning

47:42

and I'm really inspired to learn

47:44

and share it with all of you

47:46

and I'm pleased to take up any questions if there are

47:50

any. Thank you so much.

47:51

Well, Dr. Singhal, thank you so much

47:53

for giving another great noon conference lecture

47:56

and so many before this.

47:58

We really appreciate your teaching.

48:01

We will open the floor now to questions,

48:04

so if you wanna put those into the q

48:06

and a feature that would help us get through as many

48:10

as we can Before we need to close Dr.

48:13

Singal, can you pop open that q and a box?

48:15

Do you see there's a couple in there already

48:17

for you or I can,

48:18

Yes, I found It. Awesome.

48:19

48:21

So do the septations

48:23

of thyroid adenoma also have vascularity?

48:28

Yes, you can. The can have because you can have,

48:31

but they don't mean anything.

48:34

You very rarely do you see,

48:36

but it doesn't really mean anything.

48:38

Uh, it's not that you're looking at malignancy

48:41

and biases on septal vascularity

48:43

that you'll be able to protect us.

48:44

So, uh, unlike wear masses

48:47

or anything, if you are thinking on those lines, yes, uh,

48:52

I wouldn't, uh, give much value to it.

48:55

The capsular connect with the thyroid, the new chaotic

49:00

vascularity, those are the features that suggest worse ancy

49:03

with the amount of volume of work

49:05

that I've done in localizing these,

49:07

I wouldn't even think about that.

49:09

Thank you for your question.

49:11

Okay, so the next is how

49:13

to differentiate a very vascular thyroid

49:15

nodule from a parathyroid.

49:17

Can we, if any, and confirm any incidental parathyroids

49:21

and f any of of presumed thyroid nodules?

49:24

So how to differentiate a very vascular thyroid

49:27

nodule from a parathyroid.

49:28

So vascularity is not the criteria to differentiate

49:32

a thyroid nodule from a parathyroid.

49:35

It is the typical vascular signature that can guide you,

49:38

whether it's a parathyroid

49:39

or a thyroid like I explained with the clips

49:43

and with the cynic clips

49:44

and with the eccentric a room vascularity

49:47

and the polar feeding vessels.

49:49

So vascularity is just not a criteria.

49:52

Do your clinical correlation, typical location capsule

49:57

appearance, it's is the lesion intra thyroidal

50:01

or extra thyroidal?

50:02

And how is the vascularity?

50:04

And can we do FA and confirm FNA is not recommended?

50:07

My thyroid surgeon would never say that I want

50:10

to put a needle into a parathyroid, you know, no,

50:13

they don't do it for various reasons.

50:15

They don't, they don't recommend putting a needle

50:18

into a parathyroid.

50:20

And any incidental parathyroidal nodules on FNA

50:24

of presumed thyroid nodules?

50:26

I haven't seen any, I don't think so

50:28

that you put a needle in on a presumed thyroid, no.

50:30

And it's come out to be an a better

50:32

thyroid, highly unlikely.

50:34

I'm sure if you are doing, looking

50:36

for an ectopic gestational sac,

50:38

you are looking at the serum beta CGP four

50:41

from today onwards.

50:42

You'll look at the calcium and the PTH levels

50:46

before you begin to think parathyroid.

50:49

So that's a very important uh, point that will help you, uh,

50:53

screen out and eliminate those cases.

50:55

Thank you for your question Dr. Thi. Thank you.

50:59

Another question for Mr. Uh, from Dr. Pia.

51:02

Is it possible to differentiate by ultrasound subtle

51:05

or small parathyroid adenoma

51:08

from normal parathyroid gland in patient

51:10

with undiagnosed hypercalcemia?

51:12

Like I explained, I normally don't see

51:14

normal parathyroid gland.

51:16

I only see when they are deceased or enlarged.

51:19

So, uh, subtle or small parathyroid.

51:23

So undiagnosed hypercalcemia.

51:25

So if there is a clinical hypercalcemia

51:27

and if you see, uh, a subtle gland, then

51:32

of course it might be the point of origin

51:36

of the parathyroid hormone in the body.

51:38

You can do further imaging, pet CT or a co d CT to confirm,

51:43

but yes, uh, you don't normally see a normal parathyroid.

51:46

Thank you for your question.

51:49

Uh, another question by an anonymous attendee,

51:52

do you use PET CT routinely attend station

51:55

or just standard when our system may be scanned reserve PET

51:58

CT for intermediate or challenging cases?

52:03

Uh, I think, um, uh, spec C is not done for all cases,

52:08

but we can, uh, uh, planar images are taken

52:13

and then if there is any need, they would do it.

52:16

And ultrasound with the work that I'm doing with the lessons

52:21

of, uh, all the great faith with the, uh, volume

52:25

of the work at my institute

52:27

and what I've learned is a great deal of confidence level

52:30

because I recently had another pregnancy with PH pt, so

52:36

many times you can't do any other test also.

52:39

So the reliance

52:40

and the confidence level of your communication

52:43

with your physician and the trust level

52:44

really, really goes up.

52:46

So you can do spread ct, many places do it for all.

52:50

That's okay, but we still need a cross-sectional imaging

52:53

to confirm whether it's an ultrasound or a CT

52:56

before you take the patient up for surgery.

53:00

Normal measurements to differentiate from hyperplasia,

53:04

hyperplasia is histopathology.

53:06

It's not about the size.

53:10

Okay, so hyperplasia, adenoma, carcinoma,

53:12

these are histopathological words,

53:15

these are not size related words.

53:18

Okay? So measurements are not a point in consideration here.

53:23

Okay, so normal parathyroid, uh,

53:26

like they say the normal four to six seven is

53:29

what the normal parathyroids are.

53:31

So adenos like the smallest adeno I may have seen is maybe

53:35

eight millimeters, eight millimeters flattened,

53:39

three millimeter weight of in a pregnancy with PHPD,

53:43

really very subtle sleeping parathyroid.

53:46

So which was again a very challenging diagnosis.

53:49

A seven month.

53:51

At seven months, the patient presented with loss

53:53

of fetal movements and the patient was taken up for surgery

53:56

and then she had a normal pregnancy

53:58

course and a normal delivery.

54:00

Okay, thank you for your question. Question from Judith.

54:05

How do you conclusively differentiate

54:07

thyroid from parathyroid?

54:08

Not dual, especially if they are diffused.

54:12

What is diffused the parathyroid or the thyroid?

54:15

So if you have a diffuse thyroid disease

54:18

and if the equ texture of the thyroid parenchyma is uh,

54:22

abnormal, yes it is a challenging situation

54:26

because the relative contrast is not.

54:28

So there again, your saving

54:31

solution is the vascularity pattern

54:33

and of course your lot of your experience goes in

54:35

and your clinical index of suspicion

54:38

and uh, and those are the factors.

54:42

So not by the thyroid.

54:44

Adenoma normally would have some kind

54:47

of a thyroid eco extra feel

54:50

and a parathyroid adenoma is more hyper coic

54:53

and a different eco extra feel generally speaking.

54:56

However, they can be variations in both

55:00

and yeah, that those would be the queue

55:03

and use a higher frequency transducer you have,

55:06

you'll be able to see more detail at thyroid

55:09

or you may show some halo speculations, calcifications

55:13

and other things may give you more insight

55:18

how to deficient acute, chronic

55:21

or acute MM isn't any chronic or acute

55:25

and hyperparathyroidism.

55:28

Um, if there's anything more you want to add

55:30

to your question, please add.

55:32

Thank you. Uh, John's asking with cystic changes,

55:37

do you include necrotic

55:38

or cystic degeneration

55:39

of a lymph node from next squamous cell carcinoma?

55:42

We're not talking about neck lymph nodes,

55:45

cystic degeneration here C first.

55:49

We have actually differentiated it from a, uh,

55:53

from a lymph node or a thyroid not yield.

55:55

So we are only talking about the parathyroid,

55:57

talking about the neck lymph nodes.

56:00

We can talk on a separate, uh, session altogether.

56:04

So assisted degeneration in the lymph node,

56:06

the malignant lymph nodes, the metastatic lymph nodes,

56:09

those, those are totally a big different chapter altogether.

56:13

So those are not part of, uh, this reporting at all.

56:19

Can ultra, uh, so khi is asking,

56:22

can ultrasound be used in previous operated lesion

56:25

of parathyroid in cases of recurrence?

56:27

Oh yes, certainly. A lot of my work is there.

56:31

So many times there are multiple, like I said,

56:34

there was a case that I discussed, so assumed thyroid,

56:39

uh, intra bilateral intra parathyroids, which turned out

56:44

to be thyroid follicular as the patient had total

56:47

thyroidectomy came with a recurrence, right?

56:50

And then we did the scan, right?

56:52

We found the parathyroid now, right?

56:56

So yes, of course, definitely it has a

56:58

great tremendous stroke.

57:00

Okay, any particular reason why we don't FNA parathyroid?

57:04

Mm, I don't know, capsular breach or something?

57:08

My surgeon doesn't want it, it's a surgeon's question.

57:11

I will also have to clearly find out,

57:13

but they don't want me to do the FNA, the parathyroid.

57:16

It doesn't give any, they do the parathyroid wash out.

57:20

They they do the,

57:24

they do the parathyroid wash out

57:27

because results are also equally vocal.

57:29

They aren't very convincing.

57:31

They can sometimes, uh,

57:34

not give you much further information.

57:37

Signs of acute and chronic cases.

57:40

There isn't any acute or chronic here.

57:42

Just a question apart from parathyroid,

57:44

are there any some special techniques you use

57:47

to do thyroid FNA in a vascular nodule

57:50

as a vascular nodule usually gives FNA yielding more blood

57:53

weight and non-diagnostic results.

57:56

This is a question I know it's apart from parathyroid.

58:00

So it's a, it's a question for interventional radiology.

58:03

For a thyroid FNA.

58:05

So a vascular nodule, you will have to just sample an area

58:09

where you have more heimer and put your needle there.

58:14

That's your best wear when you do the color doctor,

58:16

when you see it's very vascular, you put your needle

58:19

where there is lesser vascularity

58:22

and more of parenchyma so you actually get a cellular

58:25

diagnosis rather than the blood.

58:27

That would be my tip to you. Thank you for your question.

58:29

Thank you for your interaction

58:30

and thank you for your presence, which is done first.

58:33

Ultrasound system eb, when there is a bio clinical diagnosis

58:37

of hyperparathyroidism, technically logically,

58:41

most places would do a system EB first

58:44

and then an ultrasound.

58:45

But however many of my patients come to me

58:49

for an ultrasound depending on their schedule

58:51

for both the examination,

58:53

sometimes they just get the system maybe done on the same

58:55

day and they come for ultrasound.

58:57

But I usually prefer them to come to me for ultrasound first

59:01

because after that nuclear uh, medicine test,

59:05

I think they're advised to really be, uh,

59:07

in their own domain for 24 or 48 hours.

59:10

So ultrasound

59:13

and if you want the correlation with the other imaging,

59:16

so then you can do that.

59:18

So if it's done system maybe is done beforehand,

59:21

it helps you to correlate

59:22

and gives you more definitive diagnosis.

59:25

So many times my system EP colleagues call me that,

59:30

look, this is what I'm finding,

59:31

what did you find on ultrasound?

59:33

So it's like we are both communicating with each other

59:38

ultimately in the best interest of the patient

59:39

to give the most accurate report to the patient.

59:42

So any can be done

59:43

before, ultimately they both have

59:46

to be interpreted in their own light

59:48

and of course clinically correlated together as well.

59:52

Thank you so much for your question. So Dr.

59:55

Eth Helmi is asking, do you recommend intraoperative

59:58

ultrasound during parathyroid surgery?

60:01

Well I have gone to the OT to support in the diagnosis.

60:06

Uh, so when my surgeon has called me that look I'm not able

60:10

to find it, can you come and help?

60:12

I have done it however it's very challenging.

60:16

So I feel I can do a,

60:18

give a lot more information if I do a very nice thorough

60:22

scan, uh, pre-op.

60:25

And the other thing which most, uh, attending a lot

60:28

of head in its conferences and talking to all the surgeons

60:31

and everybody is that just

60:33

before taking the patient up for surgery and ultrasound just

60:37

before the SUR surgery

60:39

and marking with a pen of the site of the location

60:43

of the nodule is very helpful to the surgeons in the ot.

60:48

That's another tip that can be done.

60:51

What's the diagnosis of a single nodular?

60:54

About seven mm large and classified thyroid?

60:57

No, I mean you have to interpret in the light

61:00

of the given clinical situation as to

61:03

what you think it could be.

61:05

That's about it. You cannot, uh,

61:08

just base it on one point factor alone.

61:12

Thank you. Is the treatment of adenoma always surgical?

61:15

Yeah, it's, it's making,

61:18

unless the patient's happy to go on with

61:22

that excessive parathyroid hormone level, it has

61:24

to be removed surgically.

61:25

What else can you do? I mean if it's a secondary

61:30

hyperparathyroidism, which you know is probably due

61:33

to vitamin D deficiency, so then of course you will go

61:36

and first correct the vitamin D If it's due

61:39

to renal disease, then of course a patient when

61:42

has undergone transplant and then it's corrected.

61:45

So it's all done. But if it's still persistent

61:47

and it's still now,

61:49

if it's still persisting postrenal transplant, now

61:52

that parathyroid may impact the kidney.

61:54

So then we may need to take it out.

61:56

So again, this is a in secondary

61:58

and tertiary, it's a call for the surgeon and MEN cases,

62:03

but most patients for the primary parathyroidism,

62:06

the treatment of choice is surgical.

62:09

And in my textbook I've given the indications for surgery

62:12

and where surgery, what are the areas where surgery is done.

62:17

So I would really urge all the institutes to

62:21

purchase the book for the institute.

62:23

And it's really 12 chapters just on parathyroid ultrasound,

62:28

really eye-opening, a lot of wonders

62:31

that you can do with ultrasound imaging.

62:33

Thank you everyone for listening.

62:35

Thank you for all your questions.

62:36

I really enjoyed interacting with all of you. Thank you.

62:41

Well, thank you so much for getting

62:42

through all those questions Dr.

62:43

Singal. Appreciate it.

62:46

And thank you to everyone else

62:47

for participating in this NOOM conference

62:49

and asking such great questions.

62:51

You can access the recording of today's conference

62:53

and all of our previous noom conferences

62:54

by creating a free account.

62:56

We will also email out a link to the replay

62:59

of this NOOM conference later today.

63:01

Be sure to join us next week on Wednesday,

63:03

March 5th at 12:00 PM Eastern,

63:05

where Dr. Kevin Chang will deliver a lecture

63:08

entitled MRI of the pancreas.

63:10

You can register for that@mrionline.com.

63:12

Follow us on social media

63:13

for a few updates on future NOOM conferences.

63:16

Thanks again for learning with us and have a great day.