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Parathyroid Surgery

Parathyroid glands regulate calcium levels in the body
Abnormal parathyroid glands cause hyperparathyroidism, raising blood calcium levels and leading to various symptoms
Treatment options include surgical removal of the affected glands, with advanced imaging techniques aiding in localization. Minimally invasive parathyroidectomy is a preferred approach

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Overview

What are parathyroids and what can go wrong?

The parathyroid glands are actually four tiny glands that sit in the lower neck. They are found very near another gland in the neck called the thyroid gland. Although the parathyroid glands may lie very close to the thyroid or even be found inside of it, they have a very different function. While the thyroid regulates energy levels and growth, the parathyroid glands regulate calcium levels in your system.

The parathyroid glands regulate calcium in your body by making more or less of a hormone called parathormone (or PTH as it is also called). The parathyroid glands constantly measure calcium levels in the blood as it flows through them. If the calcium level gets high and is unsafe for your body, the normal glands sense this and decrease or stop their hormone production. This in turn lowers the calcium in your body and all returns to normal. Abnormal glands are unable to do this. They make too much hormone and continue to raise the blood calcium even when it is already very high.

What can go wrong with your parathyroid glands?

When one or more of your parathyroid glands become abnormal it is called hyperparathyroidism. In this situation, your gland (or glands) make too much (“hyper”) parathyroid hormone. Too much hormone raises blood calcium to unsafe levels. High blood calcium causes many symptoms and problems for your body including brittle bones, premature fractures, bone pain, general loss of energy or fatigue, depression, gastric reflux, kidney stones, and high blood pressure. In short, the bodily system has a major malfunction.

Instead of stopping the rising calcium as it should, the parathyroid gland only makes it go higher. This problem occurs because one (more rarely more) of the parathyroid glands stops working with the rest of the body. It develops a growth (also called an adenoma) and swells to a larger size. It no longer senses calcium levels in the blood and instead of listening to what the body needs, just keeps raising the calcium level. Like a “runaway train” the calcium level gets higher and higher and the symptoms and problems you experience get worse and worse. 97% of the time only one of the glands is the culprit. It develops a benign growth called a parathyroid adenoma.

Less commonly (2-2.5% of the time), a person will develop enlargement of all four glands. This is not an adenoma but is called hyperplasia. Even more rare is a condition where an individual will develop enlargement of just two glands, which is called “multiple adenomas”. And finally, much less than 1% of the time, a malignant growth may be found in the abnormal parathyroid.

What are the symptoms of parathyroid gland disease and what is the best treatment?

Symptoms of parathyroid gland disease

Parathyroid gland disease causes many problems. At first, individuals may be free of symptoms. But as the abnormality persists symptoms occur and they escalate. These may include:

Premature thinning of the bones (osteopenia)
Severe bone loss (osteoporosis)
Bone fractures
Kidney stones
High blood pressure
Gastric reflux
Ulcers
Bone pain
Cardiac atrial arrhythmias (rare)

Some people may have had high blood calcium for several years before a parathyroid problem is suspected and identified. Many of these individuals will not have any of the major symptoms just described. In fact, many of these people don’t think they have any symptoms at all! Usually, however, they will have been experiencing some of the more nonspecific symptoms such as:

Unfortunately, people may often attribute these symptoms to “getting old” or “being out of shape” or “emotional issues” like depression. It is very important that high blood calcium be detected and evaluated. Even a slight elevation of calcium can be an early warning sign that diagnosis and treatment are needed.

Treatment options

There are two treatment options available to you: a watchful waiting approach or surgical removal.

Surgery is the only cure for primary hyperparathyroidism. Surgical removal is strongly advocated by physicians who frequently diagnose and recommend treatment for parathyroid disease.

If you are reading this section, then you or a loved one has probably been diagnosed with hyperparathyroidism and high blood calcium. With current advanced techniques, parathyroid surgery is very well tolerated and carries few complications. Furthermore, studies have shown that elderly patients enjoy the same benefits from successful parathyroid surgery as younger people do.

How do we identify the abnormal parathyroid glands?

Cervical Ultrasound and Nuclear Scintigraphy (Sestamibi Scan)

The traditional methods for parathyroid imaging are cervical ultrasound (US) and nuclear scintigraphy (sestamibi scan). These two imaging modalities are often used together to allow for identification and localization of the abnormal parathyroid gland. US enables precise anatomic localization and may be very accurate for normally positioned parathyroid adenomas. While the spatial resolution of a sestamibi scan is lower than that of US, it is able to identify parathyroid glands located outside of their normal position (i.e. upper neck or chest) that can be missed with US.

4D CT Parathyroid Scan

Four-dimensional CT has advantages in common to both US and scintigraphy. It provides excellent detail for preoperative localization, while the multiple phases show uptake characteristics that help to differentiate parathyroid lesions from lymph nodes and thyroid nodules.

How is parathyroid surgery usually performed?

Minimally Invasive Parathyroidectomy

Minimally invasive parathyroid surgery refers to the utilization of a small incision on the anterior neck, usually less than 2.5 cm. To select patients for minimally invasive parathyroidectomy surgery, the surgeon needs precise localization of the parathyroid adenoma and to exclude multiglandular disease.

The advantage of pre-operative localization is that it allows the surgeon to directly target a single gland for removal. Some surgeons may also use radio-guided (sestimibi detection with a gamma probe) to aid in adenoma localization during surgery.

Once the abnormal gland has been removed, intraoperative parathyroid hormone levels can be measured to determine if all abnormal glands have been resected. Further gland exploration is usually not needed.

The cure rates of minimally invasive parathyroidectomy surgery and four gland exploration are similar, but minimally invasive parathyroidectomy surgery has the advantages of better cosmetic results, shorter operating time and reduced complication rates.

Four Gland Parathyroid Exploration

Parathyroid glands can sometimes be difficult to find. Additionally, 30 percent of people can have more than one parathyroid adenoma that may not be identified with pre-operative imaging. If your affected parathyroid gland(s) cannot be located prior to surgery, all four of the glands (two on each side of the neck) will be explored during surgery with identification and removal of the abnormal gland(s). While this approach may require a larger incision, in most cases patients are discharged home the same day.

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