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British Journal of Oral and Maxillofacial Surgery 50 (2012) e33–e35

Short communication
Not all radiolucencies of the jaw require enucleation: a case
of brown tumour
Srikanth Gangidi a,∗ , Robert Dyer b , David Cunliffe a
a Department of Oral and Maxillofacial Surgery, Torbay Hospital, Torbay, Devon, United Kingdom
b Department of Diabetes and Endocrinology, Torbay Hospital, Torbay, Devon, United Kingdom

Accepted 22 August 2011

Available online 13 September 2011

Abstract

We describe a case of brown tumour from primary hyperparathyroidism, which presented with radiolucency in the jaw. It was treated by
parathyroidectomy, which resulted in complete resolution of the lytic lesion without any surgery to the jaw. It is important to be aware of
endocrine causes of a common radiological sign to avoid unnecessary local surgical intervention.
© 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Brown tumour; Primary hyperparathyroidism; Enucleation; Mandibular radiolucency; Hypercalcaemia

Introduction multinodular thyroid goitre, and generalised body aches that

Radiolucencies of the jaw are common findings in maxillo-
facial clinics. They are often of odontogenic origin, and are
usually managed with enucleation. Rare causes of radiolu-
cencies include brown tumour from hyperparathyroidism;
this diagnosis is important, as local surgical intervention such
as enucleation is not necessary.
We describe such a case and highlight the importance of
taking a comprehensive history and focusing the investiga-
tions so that appropriate treatment can be given.
Case report
An 83-year-old woman presented to the maxillofacial depart-
ment with mandibular pain beneath her lower denture.
Systematic history and examination showed a longstanding
∗
Corresponding author. Tel.: +01752 763202.
E-mail addresses: sgangidi@nhs.net (S. Gangidi), robert.dyer@nhs.net
(R. Dyer), david.cunliffe@nhs.net (D. Cunliffe).
interfered with mobility.
Oral examination showed an edentulous maxilla and
mandible, which were otherwise normal, but radiological
imaging showed a radiolucency in the right mandibular body
that was unilocular and well defined, but not corticated
(Fig. 1). In view of her systemic symptoms and thyroid signs
(thyroid disease is present in 40% of patients with primary
hyperparathyroidism) biochemical investigations were car-
ried out, which showed marked hypercalcaemia (corrected
level 3.60 mmol/L, range 2.10–2.55), and associated hyper-
parathyroidism (parathyroid hormone (PTH) 62.8 pmol/L,
range 1.6–6.9).
A subsequent radiological skeletal survey showed lytic
lesions that affected the left glenoid fossa and lateral part of
the left iliac blade, which were in keeping with osteitis fibrosa
cystica. Iliac trephine biopsy examination confirmed a giant
cell tumour consistent with a brown tumour, and a consequent
sestamibi scan showed the presence of a functioning right
inferior parathyroid adenoma. In this context, together with
its radiological characteristics, the mandibular radiolucency
was considered to be a brown tumour, so no further biopsy
examination was carried out.

0266-4356/$ – see front matter © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2011.08.009
e34 S. Gangidi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) e33–e35
Fig. 1. Orthopantogram showing a well-defined radiolucency consistent
with a brown tumour affecting the right mandibular body.
Fig. 2. Right inferior parathyroid adenoma.
In accordance with National Institute of Health
guidelines for the surgical management of primary
hyperparathyroidism,1 our patient had right inferior parathy-
roidectomy (Fig. 2) with simultaneous total thyroidectomy
for the multinodular goitre. Intraoperatively, PTH concentra-
tion (t1/2 = 3–5 min) taken 15 min after the adenoma had been
removed confirmed a level within the normal range, which
indicated successful removal of the affected gland.
Postoperatively, biochemical variables monitored accord-
ing to hospital protocol for thyroid and parathyroid surgery
showed mild hypocalcaemia, which was managed with cal-
cium supplements. Diagnosis of parathyroid adenoma was
confirmed histologically.
At 6-month review, the mandibular pain had resolved
completely and the patient’s mobility had improved consid-
erably. An orthopantogram showed complete regression of
the mandibular radiolucency (Fig. 3).
Discussion
Hypercalcaemia from raised PTH is often chronic and is usu-
ally found on routine biochemical testing, as patients are
commonly asymptomatic or minimally symptomatic. They
Fig. 3. Orthopantogram taken 6 months after the parathyroid adenoma had
been removed showing complete resolution of the radiolucency in the right
mandibular body with no local operative intervention.
can present with polyuria, polydipsia, and renal calculi,
as well as with tiredness, poor concentration, and gener-
alised body aches. Other causes of parathyroid-mediated
hypercalcaemia are primary hyperparathyroidism (parathy-
roid adenoma, parathyroid hyperplasia, and parathyroid
carcinoma), tertiary hyperparathyroidism, familial hypocal-
ciuric hypocalcaemia, and lithium therapy. Causes of
non-parathyroid-mediated hypercalcaemia are malignancy-
associated hypercalcaemia, granulomatous diseases (for
example, sarcoidosis and tuberculosis), endocrinopathies
(such as hyperthyroidism and adrenal insufficiency), drugs
(thiazides, calcium supplements, vitamin D), and immobili-
sation.
Hyperparathyroidism, the third commonest endocrine dis-
order after diabetes mellitus and thyroid disease, can appear
in primary, secondary, or tertiary forms. Primary hyper-
parathyroidism is the commonest, with a reported incidence
of 4/100 000/year.2 It has an overall prevalence of 2–3%,3
affects women more than men between the ages of 50 and
60 years, and in 40% of cases there is concurrent thyroid
disease.4 Its most common cause is a single parathyroid ade-
noma (80%). Other causes include double adenoma (5%),
multigland parathyroid hyperplasia (15%), and parathyroid
carcinoma (less than 1%).5
Chronically raised PTH increases bony remodelling (with
greater osteoclastic than osteoblastic effects), which leads to
osteopenia and osteoporosis. These bony effects can lead to
brown tumours, which present as lytic, focally well-defined
lesions. In the jaws they are a rare cause of radiolucency
(roughly 1%).6
Mandibular radiolucencies are common in patients attend-
ing maxillofacial clinics. Although the incidence of brown
tumours from primary hyperparathyroidism is rare, this report
highlights the importance of taking a comprehensive history
to guide appropriate investigations and aid diagnosis.
If a brown tumour is suspected, an initial test to measure
calcium would first rule out hyperparathyroidism. If raised,
then a subsequent PTH test would indicate which differential
group to investigate further.
Our case also shows that after surgery to remove
the parathyroid adenoma, subsequent normalisation of the
 S. Gangidi et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) e33–e35
metabolism led to complete resolution of the brown tumour
without local operative intervention.
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