Parathyroid adenomas (PAs) are the most common cause of primary hyperparathyroidism. Presentations can range from the classic bone pain, depression, fatigue, renal calculi, and gastrointestinal tract symptoms to asymptomatic calcium level elevation detected on a serum chemistry panel. They are benign tumors that are not generally thought to cause recurrent laryngeal nerve paralysis.
A 71-year-old man noted the onset of hoarseness in May of 2006, approximately 1 month prior to presentation to an otolaryngologist. He was bothered by vocal fatigue and reported difficulty swallowing liquids but not solids. His medical history included hypertension and degenerative disk disease. On physical examination, the patient was noted to have weak vocal quality. Flexible laryngoscopy revealed right vocal fold paralysis. The consulting physician ordered magnetic resonance imaging (MRI) of the neck, which revealed a 2.0 × 2.5-cm mass in the right tracheoesophageal groove at the level of the thyroid gland. Serum chemistry panel results included a calcium level of 10.1 mg/dL and a parathyroid hormone (PTH) level of 189.2 pg/dL. (To convert calcium to millimoles per liter, multiply by 0.25; parathyroid hormone to nanograms per liter, multiply by 1.) The patient then underwent a computed tomography–guided needle biopsy of the right neck mass that revealed hyperplastic parathyroid tissue. The patient was referred to the Moores Cancer Center at the University of California, San Diego, July 6, 2006. Physical examination findings confirmed right vocal fold paralysis. Serum calcium and PTH levels remained elevated, and a bone density scan demonstrated osteopenia. Technetium Tc-99m MIBI parathyroid scintigraphy revealed a single focus of increased activity in the region of the right medial thyroid lobe. The patient was counseled that his vocal fold paralysis might be due to the mass in the right tracheoesophageal groove, and a recommendation was made for surgery.