Parathyroid Disorders and Treatment

Anatomy and Function

The term “Para” thyroid means adjacent to the thyroid. Thus, the parathyroid glands are small glands found in the neck adjacent to the thyroid gland. In general, there are four parathyroid glands in the neck attached to the posterior side of the thyroid gland. These glands are no bigger than a split pea. There are two parathyroid glands on each side of the thyroid gland.

The parathyroid glands may be found in unusual locations. These aberrant glands can be found buried within the thyroid tissue, in the upper chest (mediastinum), behind the trachea, behind the esophagus, or even near the carotid artery.  

Despite their proximity to the thyroid gland, the parathyroid glands have nothing to do with the thyroid. The sole function of parathyroid tissue is to regulate the calcium level in the bloodstream. The parathyroid gland secretes a hormone called Parathyroid Hormone (PTH level), which pulls calcium out of the bones and intestinal tract.

Disorders of the Parathyroid Glands

A Parathyroid Adenoma is a benign growth or tumor of the parathyroid tissue. It usually occurs as a single tumor, but there are rare reports of patients having two adenomas. These benign adenomas secrete an abundance of parathyroid hormone, resulting in hypercalcemia (elevated blood calcium level).

If this condition remains untreated, the patient will suffer complications such as broken bones, osteoporosis, kidney stones, kidney failure, constipation, muscle aches, bone aches, fatigue, depression and anxiety.

Parathyroid Hyperplasia is a condition that causes all four parathyroid glands to become abnormally large. Usually, this condition occurs sporadically, but there are rare cases of hereditary parathyroid hyperplasia associated with Multiple Endocrine Neoplasias (known as MEN Syndromes). Also, it is common for patients suffering from Chronic Kidney Failure to have parathyroid hyperplasia. The results of untreated parathyroid hyperplasia are the same as those noted above with a parathyroid adenoma.

Parathyroid Carcinoma is very rare and usually associated with extremely high parathyroid hormone levels. It presents as a rock hard palpable mass in the neck.

Work-up and Evaluation

Typically, the patient presents after undergoing routine blood work revealing a persistently elevated calcium level. Further blood work reveals an elevated parathyroid hormone level. Vitamin D deficiencies may cause a falsely elevated parathyroid hormone level, but these patients will present with a low calcium level. Thus, patients with low Vitamin D simply need Vitamin D supplements to improve their elevated PTH level.  

Once a patient has been found to have an elevated serum (blood) calcium and PTH level, a test is performed called a Sestamibi Parathyroid Nuclear Scan (SPECT Scan). This study will assist the surgeon in identifying whether a single gland or multiple glands will require removal. Even though this study is helpful, it is not a guarantee that it will identify the abnormal glands.

Other studies that can be useful in helping the surgeon identify the location of the abnormal parathyroid tissue are neck ultrasounds, CAT scans and MRI scans. It is up to your surgeon to decide if these studies will be necessary.

Your doctor may recommend a Bone Density Study to determine the damage to the bones from hyperparathyroidism and bone degradation. A 24-hour Urine Test for Calcium may be obtained to see if the patient is dumping calcium into the urine in high levels resulting in the potential for kidney stones and kidney failure.

Treatment

Parathyroid disease is a surgical problem. Your physician may anticipate that either only one parathyroid gland needs removal or multiple glands need removal. This depends on the pre-operative studies. Occasionally, the surgeon begins with the removal of only one gland, but ultimately has to remove multiple glands as dictated by the intra-operative findings.  

Parathyroid Surgery

Your doctor may recommend a Parathyroidectomy, which is the surgical removal of one (usually for a parathyroid adenoma) or multiple (usually for parathyroid hyperplasia) diseased parathyroid glands. This could be performed either in the hospital or an outpatient surgical center. In general, the patient is put completely to sleep (general anesthesia). The total time can range from 30 minutes to 3 hours, depending on the extent of surgery required.

An incision is made low in the neck. Occasionally a drain is placed in the neck to help reduce swelling or risk of bleeding. Your doctor will inform you to stop certain medications that thin the blood reducing the risk of bleeding.  Infection is extremely rare.  

You surgeon may opt to use various technologies in the operating room to help with the successful identification and removal of the abnormal parathyroid tissue. These technologies may include the use of an Intraoperative Nuclear Probe and/or Intraoperative Rapid Parathyroid Hormone Blood Test.

There are other structures in the neck that your surgeon needs to be careful working near. The vocal cord nerves are just deep to the parathyroid glands.  If the nerves are inadvertently injured you may experience hoarseness, breathing trouble, and even swallowing problems. Usually this is temporary, but can occasionally be permanent (<1% chance). Other nerves/muscles control the “singing voice” and may be affected by surgery and the healing process.

The four Parathyroid glands are situated adjacent to the thyroid and if all are inadvertently injured or removed, you may experience numbness or tingling in your fingers or lips. Less than 1% of the time this could be permanent, but most of the time the injury to the remaining parathyroid glands is temporary resulting in the need to take calcium supplements briefly.

Removal of part of the thyroid gland may be required to help find an elusive abnormal parathyroid gland. This occasionally results in the need to take supplemental thyroid replacement medication (i.e. Synthroid) permanently.

Under normal circumstances, you should be able to drive a car in 2 days, exercise in 1 week, and return to work in 1 week.

There are certain situations that may necessitate the need for further surgeries to remove more parathyroid glands in the future. This cannot always be predicted. This is not a failure of the initial surgery but more likely a secondary abnormality of the parathyroid glands.