Pearls for Identification of Parathyroid Glands

  • Aside from the classic description of a normal parathyroid gland being “London tan” in color and about the size of a grain of rice, there are a number of other subtle and less frequently described morphological features that aid in their identification:
    • Bloodless field:
      • A bloodless surgical field is of high importance when attempting to identify parathyroid glands:
        • As any blood staining impairs the ability to identify and assess the morphological features of the gland
    • Parathyroid glands are not palpable unless abnormal:
      • A normal parathyroid gland is soft and quite compressible on digital palpation:
        • This important feature can help to differentiate a normal gland from a small lymph node, which is normally rubbery and palpable
    • Fat pads (Figure 1):
      • The parathyroid glands are often encased in a “fat pad”:
        • Located in a region where the thymus “points” to the inferior pole of the thyroid gland (inferior gland)
        • Cranial to the ITA and generally posterior to the RLN (superior gland)
    • Vascular pedicle:
      • A small vascular pedicle can often be seen entering the parathyroid gland
    • Cope’s sign (Figure 2):
      • Bruising of the parathyroid gland that can occur with mobilization or dissection
    • “Kissing glands” (Figure 3):
      • This term is used to describe two parathyroid glands that are so close in position that they appear to a single, bilobed gland
      • Although uncommon, this possible configuration should be borne in mind when searching for a missing gland
      • Kissing glands can be differentiated from a true bilobar gland by identifying a cleavage plane between the capsules of the two glands
    • Slides under fascia:
      • The parathyroid glands are usually found within the thyroids pretracheal fascial capsule, but not adherent to it
      • This feature allows the gland to be gently slid or rolled under the fascia by a fine instrument such as a Crile
Fat pads. Visual inspection can yield many clues to aid in the identification of the parathyroid glands. Inspection should begin by looking for a fat pad located where the thymus points to the inferior pole of the thyroid gland for the inferior gland, and 1 to 2 cm cranial to the inferior thyroid artery on the posterior surface of the thyroid gland and anterior to the recurrent laryngeal nerve (as shown)
Cope’s sign. Mobilization in the area of the parathyroid gland can cause bruising and discoloration of the parathyroid gland. This sign is often subtle, but it can be an important visual cue to direct further dissection. This image shows a red-purple discoloration at the top of the thymus in the region of the inferior parathyroid gland. Further dissection allowed morphologic identification of a normal inferior gland
“Kissing” left upper and lower parathyroid glands. Parathyroid tissue was identified in a fat pad at the level of the inferior thyroid artery, which initially appeared to be a single, bilobed gland. Closer inspection revealed a cleavage plane between the lobes, which was carefully dissected, and separate upper and lower glands were able to be morphologically identified

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