Parathyroid | Dr Russell Manley | General Surgeon

What is the Anatomy of Parathyroid Glands?

There are four ‘pea sized’ lobes or glands that are located usually immediately behind the thyroid in your neck adjacent the Trachea (windpipe). ‘Para’ means ‘near’, which explains the name.

While the Parathyroid glands are part of the body's endocrine system, the thyroid and parathyroid glands are completely different. The endocrine system consists of a range of glands that secrete hormones into the bloodstream.

What hormones help regulate calcium and phosphate?

Parathyroid Hormone (PTH)
Vitamins D
Calcitonin
FGF-23

The main parathyroid hormone (PTH) is a chemical that regulates the amount of calcium, phosphorus and magnesium in the bones and blood.

What is the Impact of Parathyroid Disease

The minerals calcium and phosphorus are crucial for healthy bones. Blood-borne calcium is also needed for the proper functioning of muscle and nerve cells.

Every cell and organ in the body uses calcium as a signal to regulate their normal function. Therefore, it is crucial that calcium levels are tightly controlled.

What are the Types of Parathyroid Disease

Hyperparathyroidism

Causing abnormally high blood calcium levels (hypercalcaemia) occurs when the Parathyroid gland releases extra PTH, mainly "stealing" calcium from the bone.

This condition can lead to:

Abdominal pain
Kidney stones
Osteoporosis and fractures
Mood disturbances and fatigue
Pancreatitis (inflammation of the pancreas)

In severe elevations of blood calcium levels called "hypercalcemic crisis," a patient can become comatose or near-comatose due to organ failure.

Hypoparathyroidism

Hypoparathyroidism is characterised by low levels of PTH, this causes glands to drop hormone production, which decreases the amount of calcium in the blood. This then affects nerve and muscle cells which are unable to function properly.

Hypoparathyroidism can cause:

Teeth fail to form or be slow to emerge
Impair mental development
Addison’s disease and
dysmenorrhoea (painful menstrual periods)

Multiple Endocrine Neoplasia 1

Multiple endocrine neoplasias 1 (MEN1) is an inherited condition, characterised by tumours on at least two glands of the endocrine system.

MEN1 can involve tumours in the parathyroid glands and any other hormone producing organs including the pituitary, pancreas, adrenals and thyroid.

Who are is at Risk of Parathyroid Disease

Parathyroid Disease commonly affects more women aged 50 years and over. The most common age to be diagnosed with Parathyroid disease is the early 60's with most sufferers between 40 and 75.

Patients in this group may also have heart problems related to the high calcium.

Other ages also get parathyroid disease, but in younger patients, it is typically due to a genetic/family disorder such as MEN-1 syndrome.

What are the Causes of Parathyroid Disease

Hyperparathyroidism can be caused by:

a small tumour (adenoma) in the gland.
chronic kidney (renal) disease
particular medications, such as anticonvulsant drugs

Hypoparathyroidism can be caused by:

magnesium deficiency,
injury to the glands,
surgery on the nearby thyroid gland,
genetic disorder or
the congenital lack of parathyroid glands.

Hypocalcaemia can be caused by a lack of vitamin D

Multiple endocrine neoplasias 1 is a genetic disorder

What Symptoms of Parathyroid Disease

Symptoms of Hyperparathyroidism may include:

Pain in the bones and joints
Increased susceptibility to bone fractures
Shrinking height
Backache
Muscle aches
Thirst
Frequent urination
Abdominal pain
Fatigue
Nausea
Loss of appetite
Depression and other personality changes.

Symptoms of hypoparathyroidism may include:

Pins and needles
Brittle hair and nails
Dry, roughened skin
Muscle cramps and spasms
Convulsions.

Symptoms of Multiple Endocrine Neoplasia 1 may include:

Nausea, vomiting, black faeces
Abdominal pain,
Persistent indigestion and bloating.
Vision problems.
Weight loss.
Hypotension (low blood pressure).
Reduced sex drive.

These symptoms depend on which glands are affected.

How is Parathyroid Disease Diagnosed

Patients are diagnosed through routine blood testing or screening for osteoporosis and many patients have only vague, non-specific symptoms.

Hyperparathyroidism

Diagnostic tests for hyperparathyroidism include:

Pathology to check for calcium, phosphorus, magnesium and PTH levels;
Nuclear medicine scans or CT scans with contrast to identify where the parathyroid tumour is located
Ultrasound to localise the tumour and check for thyroid nodules
Bone density scans and X-Rays
Renal ultrasound to screen for kidney stones

Hypoparathyroidism

Diagnostic tests for hyperparathyroidism include:

Pathology to check for calcium, phosphorus, magnesium and PTH levels;
ECG to check for heart arrhythmia (irregular heartbeat).

Multiple Endocrine Neoplasia 1

Diagnostic tests for Multiple Endocrine Neoplasia include:

blood tests
radiology including MRI and CT scans.

What If Parathyroid Disease is Not Treated

If a diagnosis of any Parathyroid disease is made and is not treated it can have serious consequences for the patient’s health.

Depending on the condition untreated Parathyroid disease can lead to worsening symptoms, system failures and premature death.

How is Parathyroid Disease Treated

Hyperparathyroidism

Thorough investigation to determine the underlying cause. Usually this is due to benign hormone secreting tumour within one of the glands (Parathyroid adenoma)
Surgery - Parathyroidectomy - Surgical removal of one or more parathyroid glands in the neck.
Bone health - Helps strengthen and build bones.
Vitamin - Helps promote normal body function, growth and development.

Hypercalcaemia

By treating the underlying cause i.e. Excision of parathyroid adenoma
Dietary restriction of calcium rich foods
Medications including diuretics, calcium binding agents
Intravenous fluids and hospital admission in severe cases

Hypocalcaemia

Dietary supplementation with calcium rich foods
Calcium tablets
Vitamin D to promote calcium absorption and retention
Is usually rare and temporary after parathyroid or thyroid surgery

Multiple Endocrine Neoplasia 1

Treatment varies depending on the combination of glands affected by tumours and their size etc. In the case they are operable or other non-invasive remedies are not suitable treatment can include:

Mini-parathyroid surgery or
Parathyroidectomy

When is a Parathyroidectomy Indicated

Parathyroidectomy treatment is indicated for some patients with hyperparathyroidism (high levels of parathyroid hormone) as long term exposure to high blood calcium levels can cause significant health side effects. These include osteoporosis, bone fractures, kidney stones, stomach ulcers and depression.

How is a Parathyroidectomy Performed?

Parathyroidectomy is a surgical procedure that involves the removal of one or more of the parathyroid glands (these glands produce a hormone that increases levels of calcium in the blood).

The type of surgery depends on the type of parathyroid problem and the results of imaging investigations pre-operatively.

Minimally invasive parathyroidectomy: for patients with a single abnormal parathyroid gland that has been identified on imaging this is the approach of choice. It allows exploration of one side of the neck through a smaller incision than is conventionally used.

Gland exploration is the traditional approach to parathyroid surgery that involves a larger incision to allow exploration of both sides of the neck. This is indicated in patients who have hyperparathyroidism without an abnormal gland identified on imaging. It is also used if there is co-existing thyroid disease, in patients with hyperparathyroidism due to renal failure and patients with hereditary parathyroid diseases.

The abnormal gland (tumour) is identified and removed carefully. Sometimes more than one abnormal gland is removed. If all four glands are removed, a part of one of the glands may be implanted in the forearm or the sternocleidomastoid muscle in the neck so that its function is not completely lost.

After removal of the tissue, the incisions are then closed with absorbable hidden sutures and waterproof glue.