PARATHYROID

The four small parathyroid glands are located at the front and base of the neck at the 4 corners of the thyroid gland (Figure 1.). They are normally the size of a grain of rice. The glands produce parathyroid hormone (PTH), which regulates calcium and phosphorus balance in the body by increasing absorption of calcium in the intestines, re-absorption in the kidneys and release of calcium from our bones into the bloodstream (Figure 2).

In primary hyperparathyroidism, increased secretion of PTH occurs because one or more of the glands have become enlarged and overactive. The disease is most common in people over 60, but can also be seen in younger adults. Women are more likely to be affected than men. Radiation to the head and neck increases risk. Hyperparathyroidism in childhood is distinctly unusual.

Secondary hyperparathyroidism is a consequence of kidney failure. All four glands Increase their activity and secrete more parathyroid hormone due to absence of important chemicals from the kidney that help balance the body’s calcium level.  Over time the parathyroid glands start to work independently without being control by the level of calcium in the blood (this is called Tertiary Hyperparthyroidism).  The PTH levels continually rise and cause the fore-mentioned problems.

Signs and Symptoms

The effects of increased calcium are seen in several body systems including the skeletal (osteoporosis, bone pain, and fractures), gastrointestinal (ulcers), renal (kidney stones), and central nervous system (patient complain of feeling “foggy”, inability to concentrate, frequent headaches, depression, and mood swings). Other symptoms include fatigue, forgetfulness, high blood pressure, poor sleep, heart palpitations and more. The severity of symptoms does not correlate to the level of increase in calcium. Some patients with minimally elevated calcium will suffer from severe osteoporosis. Often patients’ symptoms are not appropriately diagnosed as relating to a parathyroid disorder, and the patients go untreated. Most patients have a few of these symptoms at the same time, but even the patients who are without symptoms find that they feel much better after surgery. In several medical studies it has been shown that 95% of patients state they feel better after surgery. Most patients feel an immediate improvement in many of the symptoms as soon as 72 hours after surgery. All patients with hyperparathyroidism will develop osteoporosis.  Taking Fosamax or Actonel will not help bones that are less dense due to parathyroid disease. Prolonged increase in calcium is very hard on the body and has been proven to correlate with a decreased life expectancy. Parathyroid disease will get worse with time in all patients. It will not stay the same, nor will it get better on its own.

Diagnosis

The diagnosis is made often by keen clinicians who note the presence of a combination of signs and symptoms. But most often the diagnosis is made by laboratory tests that show a persistent increase in blood calcium levels. This is usually followed by checking the level of parathyroid hormone PTH; an elevated PTH level confirms hyperparathyroidism. However, there are times when the calcium stays elevated without a significant elevation in PTH. A fluctuating blood calcium level that occasionally is in the normal range is a frequent occurrence in patients with parathyroid disease.

The sestamibi scan is the preferred way to localize the abnormal parathyroid gland (Figure 3). The marker used for this scan preferentially is absorbed by the active, diseased parathyroid gland. This is a very sensitive test that needs to be done by imaging centers with expertise to get accurate results. We often times get a CT scan of the neck at the same time to further study the anatomic location of the diseased gland.

Treatment

There are no drugs that will make parathyroid disease better. The only successful treatment for parathyroid disease (hyperparathyroidism) is surgery. Parathyroidectomy is the surgery to remove one or all parathyroid glands. The traditional surgical approach involved a large incision and exploration of both sides of the neck. Our team of expert surgeons utilizes the technique of minimally invasive parathyroidectomy via a small incision as well as intra-operative PTH hormonal assay to ensure a more effective and less invasive procedure. As a result, our patients’ hospital recovery course is much simpler.

Minimally Invasive Parathyroidectomy

In primary hyperparathyroidism a great majority of cases are caused by an abnormality (increased activity) in one single gland (parathyroid adenoma), that causes the remaining three glands to become dormant. A parathyroid scan (Sestamibi scan) can often times localize this one gland, allowing us to take a minimally invasive approach to this disease and removing this one gland (Figure 4). In our center, we combine the Sestamibi scan with a CT scan of the neck to improve the localization of the parathyroid adenoma. This is combined with intra-operative rapid PTH testing to confirm an appropriate decline in the level of PTH hormone and assures success of surgery, immediately, in the operating room. Due to the ease of surgery for the patient this surgery can be done under loco-regional anesthesia, with patient awake but sedated.  This may be done in cases where patients health condition precludes general anesthesia, or if the patient prefers not to have general anesthesia.

Parathyroid hyperplasia or four gland disease requires treatment of all four glands (total or subtotal parathyroidectomy), with possible re-implantation of part of one gland in the muscle, or leaving half of one gland (with its blood flow intact) to take over the function of maintaining the body’s calcium balance.  Due to anatomic variation in the location (Figure 5 & 6) and the number of parathyroid glands (three to six) Intra-operative rapid PTH testing, is crucial in effective treatment of these patients. The success rate and complication rate for parathyroid surgery is very dependent upon the surgeon’s experience.

(Fig 5) - Superior Parathyroid Variability Click on image for larger view

(Fig 6)- Inferior Parathyroid Variability Click on image for larger view

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Hospital Course
In patients that have parathyroid adenoma, and only require removal of one gland, the remaining glands take over the job of calcium balance immediately; as such they may go home right after surgery. They also:

• may resume eating and walking immediately after surgery, they can even go out to eat the night of surgery or the day after
• shower two days after surgery
• follow up in one week after surgery with their surgeon, and internist/endocrinologist
• may resume exercising three weeks after surgery
• need to be aware of they symptoms of low calcium levels (numbness and tingling around the lips and fingers) and know how to treat it immediately (usually by taking 2000mg of calcium supplements, and at times Rocalcitrol)
• may return to work usually in 5-7 days

In patients that have a parathyroid hyperplasia or four gland disease, all parathyroid glands need to be identified and removed. Reimplantation of part of one gland or leaving ½ gland with its blood flow intact allows that gland to take over the job of calcium balance.  This usually takes some time, and the patients are hospitalized until their calcium replacement regiment maintains their blood calcium levels adequately. They also: 

• may resume eating and walking immediately after surgery
• shower two to three days after surgery
• follow up in one week after surgery with their surgeon, and internist, endocrinologist, or nephrologist
• may resume exercising three weeks after surgery
• may return to work usually in 7-10 days