Sinking Stones and Fluorescent Undertones: Intraoperative Parathyroid Identification Technique

Ectopic parathyroids account for 6% to 16% of primary hyperparathyroidism cases, which are definitively managed with surgical resection. Preoperative localization techniques, including ultrasonography, technetium-99m sestamibi scintigraphy, and single-photon emission computed tomography, are well-described but far fewer intraoperative localization techniques within the mediastinum are described. We present a 3-pronged approach to intraoperative ectopic parathyroid localization in a 66-year-old woman referred after preoperative technetium-99m sestamibi scintigraphy demonstrated anterior mediastinal uptake. Intraoperatively, the adenoma was identified with intravenous administration of indocyanine green, a delta parathyroid hormone assay >50%, and a postresection qualitative densitometry test. This method mitigates unnecessary dissection and reduces operative time.