A 29-year-old male patient was referred from endocrinology to maxillofacial surgery service in 2004 with a diagnosis of maxillary tumor under study.
Its morbid history includes chronic renal failure diagnosed at 18 years of age, on hemodialysis 3 times a week.
At 27 years of age, a Doppler ultrasound detected bilateral nodules consistent with parathyroid adenoma and PTH levels of 2,448 pg/ml (150-500 pg/ml).
With this background secondary hyperparathyroidism was diagnosed.
Partial parathyroidectomy was performed and protocol pharmacological treatment was indicated, obtaining normalization of serum calcium levels, but maintaining high levels of parathyroid hormone.
The patient notes volume increase in the left maxillary area, slow growing but progressive with 2 years of evolution, since 2002.
At the time of consultation in our service, clinically there is an increase in volume that compromises the left maxilla in its anterior, posterior face and hard palate, of firm consistency, of 4 cm in diameter, painless mucosa appearance, shaped, skin and bad smell.
Radiographic examinations show multiple osteolytic images that affect the skull, mandible and left maxilla.
The CT scan showed an exophytic tumor involving the left maxilla, maxillary sinus, nasal cavity and floor of the left orbit.
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An incisional biopsy of the lesion was performed.
Histopathological study describes multiple trabeculae of immature bone tissue and a fibrous matrix where multinucleated giant cells are observed.
Laboratory tests show serum calcium of 12.6 mg/dl (8.1-10.3), alkaline phosphatase-5500 pg/dl (8.1-289 UI/ml), inorganic phosphorus 56.7 mg/dl (150 pg/dl).
With all this background a brown tumor of the left upper jaw was diagnosed.
It was decided to perform total parathyroidectomy and maintain an expectant management regarding the brown tumor, expecting a possible spontaneous remission with the normalization of PTH, calcium, phosphorus and alkaline phosphatase values.
The treatment plan also includes periodic clinical, radiographic and laboratory controls to evaluate the behavior of craniofacial lesions.
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Two months after total parathyroidectomy and normal PTH function values were achieved, there was no evidence of maxillary tumor remission.
Considering the involvement of neighboring anatomical structures and possible complications, surgical treatment of the lesion was decided.
Under general anesthesia and nasotracheal intubation an incision is made on the inner side of the upper lip from the midline to the tuberosity.
A mucoperitic flap up to the suborbital plume was raised, exposing the tumor extensively.
Exeresis of a large part of the lesion was performed through osteotomy with a reciprocing saw in the pediculate area that was attached to the anterior and lateral wall of the maxillary sinus preserving bone void.
Closure is achieved by first intention.
The postoperative course was satisfactory and the patient was discharged after 72 h.
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Postoperative clinical and radiographic controls were performed. Clinical evidence of facial symmetry was evident, with no compromise of sensitivity and no recurrence during the 7 years after tumor resection.
