Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery.
This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)—both label free and in combination with indocyanine green—based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery.
Conclusions and Relevance
Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: November 15, 2022.
Published Online: January 12, 2023. doi:10.1001/jamaoto.2022.4421
Corresponding Author: Amanda L. Silver Karcioglu, MD, Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, NorthShore University HealthSystem, 9669 Kenton Ave, Ste 206, Skokie, IL 60076 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Triponez reported personal fees (consulting fees paid to institution) from Medtronic, Fluoptics, and Stryker during the conduct of the study. Dr Almquist reported grants from IPSEN and Medtronic outside the submitted work. Dr Benmiloud reported personal fees from Fluoptics (consulting) outside the submitted work. Dr Berber reported personal fees from Aesculap, Medtronic, Johnson & Johnson, and Intuitive outside the submitted work. Dr Cha reported grants from Children’s National Hospital (NIH 2 R44 EB030874-02) during the conduct of the study; grants from Optosurgical (NIH 2 R44 EB030874-02) outside the submitted work; a patent for US17/854,084 pending; and is the founder and scientific advisor for Optosurgical and has a financial interest with the company. Dr Mahadevan-Jansen reported grants from Medtronic (in-kind) during the conduct of the study; in addition, Dr Mahadevan-Jansen has a patent for NIRAF for parathyroid detection that is licensed by her institution to Medtronic. Dr Mannstadt reported grants from Takeda and Calcilytix and personal fees from Amolyt outside the submitted work. Dr Singer is a consultant for Medtronic outside the submitted work. Dr Thomas reported affiliation with Vanderbilt University, which has a licensing agreement for PTeye with Ai Biomed (now officially acquired by Medtronic). Dr Randolph reported grants (research support) from Fluoptics, Medtronic, and Eisai during the conduct of the study; Dr Randolph also reported serving as the president of the International Thyroid Oncology Group and the World Congress on Thyroid Cancer, chair of the Administrative Division of the American Head and Neck Society, and American College of Surgeons Otolaryngology Governor. No other disclosures were reported.
Additional Contributions: We thank Garyfallia Pagonis, BFA, BS (Massachusetts Eye and Ear Infirmary), for her assistance in the preparation of tables and figures, as well as Louise Collins, DVM, MSLIS (Massachusetts Eye and Ear Infirmary), for her assistance with building the search strategy of the literature review. They were not compensated for their contributions. Dr Randolph would like to acknowledge the ongoing support of Mike and Eliz Ruane and of John and Claire Bertucci for his research efforts.
Disclaimer: Dr Davies is an Associate Editor of JAMA Otolaryngology–Head & Neck Surgery but was not involved in any of the decisions regarding review of the manuscript or its acceptance.
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