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derness. The classical laboratory findings in hypcr- are asymptomatic and have no metabolic complicaparathyroidism
are hypercalcemia and hypo- tion pose an entirely differcnt poblem. No hard and
phosphatemia.. An elevated serum calcium level in fast rule exists concerning whether asymptomatic
the absence of malignancy, sarcoidosis, hypervitami- patients should undergo surgery, although current
nosis D, hyperthyroidism, thiazides, milk-alkali trend seems to favor early surgical intervention. In
syndrome or prolonged immobilization is still the best approximately 25% of asymptomatic patients, the
test for this disease. Owing to the phophaturic effect disease will progress and they will develop some form
of parathyroid hormone, hypophosphatemia is com- of metabolic complications within 5 years. The extent
monly observed in primary hypcrparathyroidism. In of surgical management of hyperparathyroidism must
the absence of renal impairment, hypophosphatemia be based on pathological entities of the disease. If
is demonstrable in approximately 70% of patients, the diagnosis of an adenoma is irreputable, excision
The definitive diagnosis of primary hyperparathy- of the diseased gland is all that is required. If primary
roidism rests on the simultaneous demonstration of hyperplasia is confirmed by the presence of more
hypercalcemia together with an index of abnormal or than 2 diseased glands, a resection of the three and
inappropriate parathyroid function - an increase serum part Of the fourth gland is mandatory. The manageparathyroid
hormone level, merit of a parathyroid carcinoma requires en bloc
resection including excision of a wide margin of normal
The radiologic findings of primary hyperparathy- tissue. Routine radical neck dissection is not recomroidism
are as diverse as the symptoms. Subperioteal mended since spread is by local extension sparing the
resorption is virtually pathognomic of the disease, cervical lymph nodes until a later date.
Other radiologic findings are "salt and pepper"
appearance of calvarium, bone 12.13 cyst, calcinosis, As regards to Brown Tumor, many cascs have
and "tugger jersey" sclerosis of spine, been reported to undergo spantaneous regression
following excision of the 3.7 disease parathyroid. In
The most common pathology in patient with a review of literature by Parrish, 3 et al; many surgeons
primary hyperparathyroidism is a single parathyroid still opted an excision of brown tumor primarily for
adenoma found in 80%, parathyroid hyperplasia (chief immediate debulking of the mass. Bohlman et al, have
and clear cells) accounted for 9%and parathyroid cited faster resolution of brown tumor with adjuvant
carcinoma accounted for 3% of patients. 2 corticosteroid therapy.
Preoperative localization is important in the
surgical 14,15 management of primary hyperpara- The prognosis of primary hyperparathyroidism is
thyroidism. Parathyroid glands abnormalities are rarely generally very good. Formation of renal calculus and
palpable. Many procedures have been devised in the some of the late skeletal changes caused by hyperquest
for a sensitive means of localization. Davidson parathyroidism would require a surgical management.
et al, in their review of parathyroid imaging, reveals However, most of the skeletal changes and other
that high frequency ultrasonography has a sensitivity nonspecific complications would revert back to norof
69-88% for most parathyroid adenoma of greater mal once the diseased parathyroid is removed.
than 5 mm. In the same study, thallium-pertechnetate
radionuclide substraction scan has a diagnostic
accuracy between 50-95%, digital stubstraction angi- SUMMARY
ography has a sensitivity of 61)-70% while computed
tomography has 50 to 70% sensitivity. In this study, This is the first reported case in our institution
it was recommended that ultrasound be the first line of primary hyperparathyroidism masquerading as
of imaging modality because of relatively acceptable maxillary mass-Brown Tumor. The diagnosis of brown
sensitivity index and more simplified and inexpensive tumor was delayed despite 2 operations primarily due
method of imaging, to nonspecificity of clinical, radiologic and histopathologic
manifestations and possibly due to unaware-
Surgery of the parathyroid is clearly indicated in ness on the part of the clinician and pathologist. Only
patients with one or more of the metabolic compli- detection and medical evaluation of hypercalcemia,
cations of hyperparathyroidism such as bone disease, demonstrating elevation of both serum calcium and
renal calculi, ulcers and pancreatitis. PatienLs who parathyroid hormone prompted search for parathyroid
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