A mediastinotomy should be undertaken only after thorough exploration of the neck, including inspection of the para- and retroesophageal space and the left thymus and right thymus.

The anterior mediastinum is exposed through an additional vertical incision from the suprasternal notch to the second or third intercostal space on either the right or left side. A complete sternotomy is done when the posterior mediastinum is explored. Appropriate care should be taken not to injure the internal mammary vessels or the pleura. The left innominate vein can be retracted or divided to inspect the anterior mediastinum.

In a series of 400 patients with primary hyperparathyroidism, 84 mediastinal parathyroid tumors were observed.69 Only 19 (5%) parathyroid tumors had to be removed through a mediastinotomy. Conn and coworkers reported that only 22% of all mediastinal parathyroid tumors required splitting of the sternum to remove the tumors.70 In this study, a mediastinal parathyroid tumor was not found when thallium-technetium scanning, computed tomography scanning, magnetic resonance imaging, or angiography of the mediastinum did not detect a parathyroid tumor. In a large series of 2770 patients with primary hyperparathyroidism, only 38 patients (1.4%) had a mediastinotomy to remove an enlarged parathyroid gland.71

Thoracoscopy has been reported to be a successful minimally invasive technique to remove parathyroid tumors located deep in the mediastinum.72

The parathyroid glands that require a mediastinotomy for removal are either ectopic lower parathyroids, which descended into the anterior mediastinum during embryologic development, or supernumerary parathyroids. The blood supply of these mediastinal parathyroids is usually derived from the internal mammary vessels. Approximately 70% of the mediastinal parathyroid glands are found within or attached to the thymus.69,71 Other locations of mediastinal parathyroids are at the ascending aorta, aortic arch, and its major branches and occasionally on the pericardium.

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