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A preoperative transesophageal exploration of the parathyroids by endosonography was performed on 23 patients with primary hyperparathyroidism. The system used was a 7.5 MHz transducer mounted on the tip of an endoscope with an external diameter of 13 mm. The field of visualization was 360 degrees. A retrograde exploration was done moving up from the aortic arch to the upper esophageal sphincter. All patients underwent surgery afterward, and adenomas were found. In 12 cases the adenoma was visualized. All 12 adenomas were posteriorly located on the right side (four cases) and left side (eight cases) of the esophagus. Nine of these 12 tumors were on the posterior face of the thyroid lobes, with six tumors in the middle one third of the thyroid lobe and three in the lower one third of the thyroid lobe. The other three tumors were located below the lower pole of the thyroid lobes in the upper posterior mediastinum. Mean tumor weight was 1165 mg. Of the 11 tumors that could not be visualized, eight tumors were anteriorly located; three of these tumors were on the anterior and lateral surface of the lower pole of the thyroid, and five were in the thyrothymic tracts. The remaining three tumors were located on the back of the thyroid lobes; two of these tumors were at the upper esophageal sphincter, and one was on the side of the pharynx. Mean tumor size was 1334 mg. Localization of parathyroid tumors by endosonography appears possible but only if lesions are located posteriorly, close to the esophagus. Endosonography is not indicated before routine cervical exploration for primary or secondary hyperparathyroidism. As in other such studies, endosonography could be useful in cases of persistent or recurrent hyperparathyroidism.

In 6307 cervicotomies for thyroid and parathyroid excision, 33 cases of nonrecurrent inferior laryngeal nerve were identified (0.52%). The anomaly was observed in 31 cases from 4921 dissections on the right side (0.63%) and in two cases from 4673 dissections on the left side (0.04%). Of the 31 patients who were initially seen with this anomaly on the right side, no innominate (brachiocephalic) artery was found; the right common carotid artery was arising directly from the aortic arch. The aberrant subclavian artery could always be felt against the vertebral column behind the esophagus. The two patients with the anomaly on the left side had a right aortic arch associated with situs inversus viscerum. In one case of invasive thyroid carcinoma, the nerve had to be sacrificed. In all of the other patients, postoperative laryngoscopic findings were normal. The nervous anomaly was of vascular anomaly origin in all cases. Predisposing factors for its onset during aortic arch development are discussed. Before surgical treatment, the diagnosis may only be made if vascular anomaly is suspected. Impairment of swallowing is the only clinical symptom to be looked for. The retroesophageal subclavian artery may be detected on chest x-ray films (20%) or by the compression and distortion of the esophagus shown during barium swallow tests (97%). Although rare on the right side and exceptional on the left, an aberrant nonrecurrent pathway for the inferior laryngeal nerve represents a major surgical risk. This is an additional argument in favor of systematic dissection of the inferior laryngeal nerve during thyroid or parathyroid excision.