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Parathyroid Glands

The Endocrine Surgery Center at Robert Wood Johnson University Hospital

Parathyroid Glands

Anatomy

Click Image to Enlarge

The parathyroid glands are pea size glands usually located behind the thyroid. Most people have four parathyroid glands, however some may have three, five or six glands.

While most glands are located behind the thyroid gland in the neck, the location of the glands can vary. When the parathyroid glands develop during gestation in the mother’s uterus, the glands may migrate from the back of the throat to anywhere from the base of the brain to the middle of the chest. The variable location of parathyroid glands is one of the reasons that parathyroid operations are challenging.

Physiology

The parathyroid glands secrete parathyroid hormone which regulates calcium in the body for proper functioning of the nervous and muscular systems. The word regulates means that the parathyroid glands keep the calcium in the blood at an even level.

The parathyroid glands respond similar to the way the thermostat in your home responds to the temperature within your home. If the thermostat is set to 70 degrees and the temperature in your home goes lower than that, it senses the lower temperature and sends an electrical signal to the furnace to increase heat production. When the heat rises in the home, the thermostat senses that and sends a signal back to the furnace to slow down or shut down its production of heat. Likewise, the parathyroid glands sense the amount of calcium within the blood. It does this through a receptor on the parathyroid cell membrane.

Normally, the serum calcium should be roughly between 8.6 and 10.4 mm/dl. If the serum calcium level is low, the normal response by the parathyroid glands is to secrete more parathyroid hormone.The parathyroid hormone acts on the intestinal lining cells to absorb more calcium from the diet. The parathyroid hormone also encourages the kidneys to reabsorb more calcium.

The bones are the greatest repository of calcium in the body and release more calcium to the blood in response to increases in parathyroid hormone secretions. When the serum calcium rises to normal or high normal levels, then the amount of secretion of parathyroid hormone by the parathyroid glands decreases. The normal relationship between the parathyroid hormone and serum calcium is inverse. What this means is that when the serum calcium level is low, the parathyroid hormone level should be high. When the serum calcium level is high, the parathyroid hormone level should be low. There is no absolute value of normal parathyroid hormone level. The level is always measured in conjunction with the serum calcium and should be appropriate to that serum calcium.

Abnormalities in the serum calcium and parathyroid hormone level are a signal that something may be wrong with the parathyroid glands.

Diseases and Conditions Affecting the Parathyroid Gland(s)

Primary Hyperparathyroidism

The main disease that affects the parathyroid gland(s) is called hyperparathyroidism. It is a condition in which too much parathyroid hormone is produced. Hyper stands for too much, parathyroid refers to the parathyroid hormone, and ism stands for a condition or disease. When a patient has hyperparathyroidism, it means that one or more of the parathyroid glands are producing too much parathyroid hormone. The amount is not related to the level of calcium as it should be. Even when the calcium level is normal, the parathyroid gland keeps producing parathyroid hormone in the individual with hyperparathyroidism.

Click Image to Enlarge

The cause of hyperparathyroidism in over 90% of people is an adenoma in one of the parathyroid glands. Aden refers to gland and oma refers to tumor. An adenoma is a noncancerous tumor. Instead of the gland being about the size of a pea, they could be more like the size of a walnut. The image to the right shows an actual adenoma removed from a patient. Note the size in relation to the ruler next to the adenoma.

A small percent of individuals with primary hyperparathyroidism have parathyroid hyperplasia. This means too much (hyper) formation of cells and enlargement of each of the parathyroid glands (plasia). An even smaller percent of individuals have two normal and two enlarged parathyroid glands. It isn’t the number of glands affected that determines the severity of disease. The effect of excessive parathyroid hormone on the body can be same whether one, two, or more parathyroid glands are involved.

It is an extremely rare condition to have primary hyperparathyroidism from a cancerous tumor in the parathyroid gland.

Hyperparathyroidism may also occur as part of a very rare hereditary disorder known as multiple endocrine hyperplasia. This means there is enlargement of several endocrine glands in the body.

Primary hyperparathyroidism should be treated by surgeons with extensive experience with parathyroid surgery. This is because the number and location of adenomas can vary from person to person. It takes someone with a great deal of experience to locate and remove these tumors. You’ll learn more about parathyroid surgery below.

Secondary Hyperparathyroidism

Secondary hyperparathyroidism occurs when the calcium level in the blood becomes abnormally low and it triggers the parathyroid gland to produce parathyroid hormone. Chronic kidney disease and vitamin D deficiency are examples of conditions that cause a severe decrease in the calcium level and result in secondary hyperparathyroidism. Treatment involves correcting the underlying cause of the problem. Vitamin D, calcium supplementation, dialysis, kidney transplantation, and parathyroid surgery are possible treatment options.

The remainder of this website will focus on primary hyperparathyroidism since the symptoms and treatment can be different from secondary hyperparathyroidism. Secondary hyperparathyroid disease does not need operative intervention.

Tertiary Hyperparathyroidism

Tertiary hyperparathyroidism can occur if secondary hyperparathyroidism persists for a long time. A parathyroid gland may become autonomous. This means that the gland produces excessive amounts of parathyroid hormone even if there is no reason to do so. Even if the stimulus of low calcium is removed by medical treatment, excessive amounts of parathyroid hormone are still produced. Parathyroid surgery is needed. It may either be a subtotal parathyroidectomy whereby only some paraythroid tissue if removed. It may also require a total parathyroidectomy with auto-transplantation. This involves the removal of all of the parathyroid tissue and reimplantation of some tissue into the muscles of the neck. The reimplanted parathyroid tissue can act like a functioning gland.

Symptoms

Individuals with primary hyperparathyroidism might not experience symptoms at all. Some experience fatigue, difficulty sleeping, irritability, difficulty remembering things, nausea, vomiting, or other vague nervous system problems. Some individuals experience bone pain or even osteoporosis. Osteoporosis is a progressive decrease in the density of the bones, making them susceptible to fracture. Gastric (i.e., stomach) ulcers and pancreatitis can also develop as a result of hyperparathyroidism. Pancreatitis is an inflammation of the pancreas gland, which is an endocrine gland located behind the stomach. Kidney stones can also develop because of the large amount of calcium that collects in the small tubes or canals inside the kidneys. If left untreated, kidney stones can progress to kidney failure.

Diagnosis

Sestamibi-Thallium Scan

This is the preferred method of preoperative localization used today.  It consists of an injection of nuclear dye and scanning of he neck within 30 minutes of the injection, and then again between two and three hours after the injection.  Initially, the salivary glands (they secrete saliva) and the thyroid, parathyroid, and heart all pick up sestamibi-thallium.  You may have heard the word thallium before since it is commonly used during a nuclear stress test for patients with angina or other heart problems.  On the second, or delayed, image at two to three hours, the parathyroid gland that is enlarged holds on to the sestamibi and shows a "hot spot".  It is usually one gland that is enlarged.  The Sestamibi-Thallium Scan is sometimes performed as a single photon emission computerized tomography scan (SPECT).

Pictured here is a Sestamibi-Thallium Scan that shows the "hot spot" for a patient who went on to have parathyroid surgery to remove an adenoma. ADD PICTURE OF SCAN HERE (compare to normal if possible).

Primary hyperparathyroidism is diagnosed by calcium and parathyroid hormone levels in the blood. Blood is drawn with a needle from the arm and is analyzed in a laboratory. If the laboratory results determine that hyperparathyroidism exists, then additional diagnostic tests are done. The surgeon or endocrinologist will order diagnostic tests to determine which of the parathyroid glands is enlarged. This is called preoperative localization.

Ultrasound

An ultrasound of the neck can be used in conjunction with the Sestamibi-Thallium Scan. It shows the exact relationship between the parathyroid glands, the thyroid, the jugular vein, and the carotid artery. If the ultrasound does not identify an enlarged gland where the Sestamibi Scan lit up (i.e., the “hot spot”), it is usually because the gland is located deeper in the neck in relation to the thyroid. This information is helpful to the surgeon who will be removing the parathyroid gland(s). The ultrasound can only demonstrate an abnormally enlarged parathyroid gland. [[ADD PICTURE OF ULTRASOUND HERE. -- have CD of photos need to identify which to use and caption]]

Other Scans

Other scans such as Computerized Tomography (CT) Scans and Magnetic Resonance Imaging (MRI) Scans may sometimes be helpful under special circumstances.

Treatment/Surgery

Each patient’s treatment regime is individualized according to the number, the size, and the location of the enlarged parathyroid gland(s), and the general health of the patient.

Surgery is the treatment for enlarged parathyroid gland(s). If a single “hot spot” was identified on the Sestamibi-Thallium Scan, then a “directed” exploration can be performed by the surgeon in the operating room. That is, the surgeon can make a small incision and go directly to the spot identified on the scan and hopefully find the enlarged gland. This can often be done using a minimally invasive approach. Minimally invasive surgery is a term that means different things to different people. Minimally invasive surgery at RWJUH is defined as surgery with smaller incisions, minimal scarring, less post-operative pain, shorter hospital stay (often same day/outpatient surgery), and a quicker recovery. It frequently involves the use of intravenous sedation and local anesthesia. Intravenous sedation involves one or more medications given through an intravenous line that is connected to an intravenous catheter inserted into a vein in the hand or arm. Local anesthesia is the numbing of the nerves of the superficial cervical plexus which are located behind the muscles in the neck. It involves the injection of the anesthetic agent with a small needle. Patients remain awake during the procedure, but are very comfortable and calm. Please see the Anesthesia section below. It describes the two anesthetic methods that can be used during parathyroid surgery (i.e., local anesthesia or general anesthesia).

If the pre-operative tests do not identify a single “hot spot”, then the traditional surgical approach is used. It involves a complete neck exploration in which the surgeon makes a more generous incision in the neck and looks for all the enlarged parathyroid glands.

This paragraph sent to Martha Smith to review since intraoperative testing procedure changed:

Whether the surgeon can use a directed neck exploration or a complete neck exploration, he/she needs to be able to determine that all of the enlarged glands producing excessive parathyroid hormone have been removed. This needs to be determined before the surgery is completed and the skin incision is closed. A blood specimen is drawn before the surgery to determine the level of parathyroid hormone in the blood. This is called the pre-operative blood level. Additional parathyroid hormone levels are drawn at five- and ten-minute intervals after the enlarged parathyroid glands (s) is/are removed. The blood is taken to the hospital’s laboratory and is analyzed right away. The results are communicated to the surgeon in the operating room so he/she knows how to proceed. If the parathyroid hormone level drops by 50%, then 95% of patients have had all of their enlarged gland(s) removed. It lets the surgeon know whether to stop the operation because it was successful or to continue to look for additional enlarged glands. When the follow-up parathyroid hormone levels drop by 50%, there is a very good chance that the patient has a long-term cure.

Notice the dramatic change in the parathyroid hormone levels for the following two patients. The parathyroid hormone level dropped 82% in each patient after removal of the parathyroid gland.

[[Insert powerpoint graphs here (graphs of parathyroid hormone levels).]] What values to graph?

Some surgeons use a nuclear probe and injection of sestamibi just prior to the operation. This is instead of the pre-op and intraoperative parathyroid hormone levels. This is generally a surgeon’s choice.

An experienced surgeon should be successful at finding the enlarged parathyroid glands during the patient’s first operation in 95% of cases. Some patients may have an enlarged gland located outside the neck area, making the surgery much more difficult. As you learned earlier, they can located anywhere between the base of the brain and the chest. If the surgery was unable to identify and remove the enlarged parathyroid gland, then additional tests will be done. They may include additional imaging studies, ultrasounds, arteriography (sampling of blood through catheters in the neck and chest), and measuring parathyroid hormone levels.

Experienced Surgeons at Experienced Hospitals

[[ADD THE RWJUH VOLUME DATA WITH EMPHASIS ON THE LARGEST VOLUME OF PARATHYROID SURGERY IN NJ PERFORMED AT RWJUH. CONFIRM THAT THIS IS CORRECT WITH DATA. EMPHASIZE THE PERCENT SAME DAY AT RWJUH AS COMPARED TO STATE)]]

Anesthesia

Your thyroid or parathyroid procedure can be performed under either General Anesthesia or Local Anesthesia with Sedation. Either method is safe, effective and routinely used at this hospital for either thyroid or parathyroid surgery. Both methods are described in this pamphlet. (Occasionally, one method may be preferred due to certain pre-existing medical conditions).

With either method you will have monitors placed to monitor your heart, your blood pressure and your oxygen. An intravenous catheter (IV) will be inserted and you will receive an electrolyte solution through your IV. This IV is also used to administer medications.

General Anesthesia

You will be given oxygen by a mask placed gently over your nose and mouth and medication will be injected into your IV and you will drift off to sleep. After you are asleep, a breathing tube will be placed in your wind pipe to facilitate your breathing and will be removed prior to you waking up. You will remain sleeping until the end of the procedure. You will receive medication for pain prior to waking up and you will also receive medication to control nausea and vomiting. At the end of the procedure, you will be transferred to the recovery room.

Occasionally, you may require additional medication for pain and nausea and this will be provided for you in the recovery room.

You will remain in the recovery room for at least one hour or until you are no longer sleepy. You will then be transferred to second stage recovery. At this point, you will be joined by your family and you will be allowed to drink fluids. You will remain in this area until you are ready to go home. Occasionally, you may be required to stay overnight and you will be tranferred from the recovery room to a hospital room.

Local Anesthesia with Sedation

You will be given oxygen via a nasal catheter and medications will be given through your IV to provide sedation. The sedatives are used with a combination of an anti-anxiety medication, a pain medication, and an anti-nausea medicine. After adequate sedation has been achieved, you will receive a local anesthetic injection by your surgeon which will numb the neck area. You will be positioned on the OR table in a beach chair position with your hands resting on your lap or at your sides.

You will remain in this position throughout the surgery. A sterile curtain will be placed over your neck, but will not cover your face. You will continue to receive medication to maintain a relaxed state throughout the procedure.

At times you may feel pulling or pressure during the procedure and may hear talking, but the medication will enable you to remain relaxed.

If for any reason you feel discomfort, you will be able to let us know and we will provide additional sedation and/or local anesthesia.

Hospital Course and Follow-up

The majority of patients at RWJUH have their surgery on an outpatient basis (CHECK IF CONTINUES TO BE TRUE. RE-EMPHASIZE STATS ABOVE SINCE 2004 DATA LOOKED GREAT IN COMPARISON TO OTHERS).

Pictured here are nurses who work in our Same Day Surgery Suite (SDSS) where patients come on the day of surgery.

[[Place picture of the SDS staff here.]]

Most patients are observed for six hours after surgery and are sent home with calcium to take by mouth. Either Os-cal 500mg with Vitamin D four times daily or Citracal 600 mg with Vitamin D four time daily is ordered. Some patients go home on Calcitrol which is an activated form of Vitamin D taken once or twice a day. These prevent the symptoms of low calcium. (REVIEW USE OF TRADE NAMES – CONSIDER JUST VIT D OR CALCIUM)

The symptoms of low calcium are tingling around the mouth and fingertips. If this happens to you after the operation, you should know that it means that the operation was successful and your bones are hungry for calcium and are taking back the calcium that has been leeched out of them. In addition, you should take another calcium pill and contact the surgeon’s office right away. The surgeon will increase the amount of calcium you are taking by mouth. If the symptoms persist, some patients may need IV calcium. This will be arranged by the surgeon’s office if needed. Usually, patients do quite well with large calcium and Vitamin D supplements and nothing more is needed.

Risks and Complications

Some risks of the operation are those similar to any other operation. Those risks relate to heart and lung problems after general anesthesia if the operation is performed that way. The risks also are bleeding, infection and an unsightly scar. Not finding the offending gland or glands is also a known risk of the operation, as previously discussed. There are also risks related usually to other structures in the neck. These occur very, very rarely but you should, nonetheless, know they exist. There are nerves at the top of the thyroid that control the ability to hit the high notes. If these are injured during the course of the operation and if you have an excellent singing voice, it may affect your ability to hit high notes. If you do not have an excellent singing voice and this nerve is injured (the external branch of the superior laryngeal nerve), you will notice no difference in your singing or speaking voice. There is a nerve behind the thyroid, on each side, called the recurrent laryngeal nerve. This nerve controls the opening and closing of the vocal cords. If one of these nerves is injured during the course of the operation, you may have hoarseness and voice fatigue that sometimes can be lifelong. If it is injured on both sides, then the vocal cords are shut and you cannot breathe without a breathing tube placed in the trachea or windpipe permanently, called a tracheostomy. This occurs very, very rarely with parathyroid surgery. We have found that every once in a while we will have a patient who has an enlarged parathyroid gland that is very closely wrapped around the recurrent nerve. Sometimes there can be swelling over the short run with temporary nonfunctioning of this nerve. This swelling improves over time and patients get better. Permanent injury of the recurrent nerve is rare but it does occur.

Follow-up for the Surgical Incision

Most surgeons use a special skin glue to close the surgical incision(s). You may expect that you will have some firmness under the scar and some thickening under the scar and even black and blue if local anesthetic was used. You may take a shower the next day. You do not need a Band-Aid or any bandages on the wound. If there is any drainage from the wound, please call the office as soon as possible. If you are concerned about redness in the wound, also call the office. If there are any problems with breathing, which is incredibly rare, please come directly to the hospital or the nearest emergency center. You will usually be required to have a number of postoperative visits, the first one within ten days of the operation. Please call for an appointment.

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