Most people have four parathyroid glands located in the neck, in the region of the thyroid gland. Normal parathyroid glands are tiny, about the size of the inside of a sunflower seed. Abnormal parathyroid glands are enlarged, about the size of a grape. These glands produce parathyroid hormone (PTH) which is responsible for controlling calcium metabolism. PTH regulates the deposition of calcium in the bones and excretion of calcium in the urine.
Diseases of the Parathyroid
Usually patients are referred to us with over-active parathyroid tissue, a condition known as Hyperparathyroidism. In approximately 90% of patients one of the four parathyroid glands is overactive. Some patients have more than one abnormal gland. Hyperparathyroidism leads to elevated PTH which causes absorption of calcium from bone thereby weakening the bones, a condition know as osteoporosis or osteopenia. This causes an elevation of the blood calcium level which in turn results in elevated levels of calcium in the urine and can result in kidney stones and, over time, kidney damage. Patients with elevated blood calcium levels can suffer from depression, fatigue and muscle symptoms.
Patients are usually referred to us with elevated blood calcium levels as well as an elevated PTH level. Once the diagnosis has been established we ask patients to undergo a radiological examination which utilizes Sestamibi radioactive marker in conjunction with special CT imaging to locate the abnormal parathyroid tissue.
Once the diagnosis of hyperparathyroidism has been established most patients are referred for definitive surgical therapy.
In approximately 80% of patients with hyperparathyroidism the offending gland can be seen and localized on preoperative sestamibi imaging. Those patients with positive sestamibi scans are candidates for Minimally Invasive Radioguided Parathyroidectomy (MIRP). During the MIRP procedure the patient receives a preoperative dose of sestamibi radioactive marker which allows the surgeon to use a hand held probe to localize the abnormal gland. This allows the surgeon to remove the offending gland using a rapid, directed approach. The operation is performed under anesthesia and takes thirty minutes to an hour to complete. Following the operation most patients are discharged within a few hours of the procedure.
Patients that have a negative sestamibi scan still have the same disease, hyperparathyroidism, but their offending glands do not take up the marker and are not visible on preoperative sestamibi imaging. These patients still need operative therapy. Frequently we can identify the offending gland using surgeon directed sonography. In these patients we expect to spend a longer time in the operating room (one to two hours) to insure that the condition is corrected.
In those patients with negative scans or multi-gland disease, our surgeons may also utilize an intra-operative parathyroid hormone blood test (IOPTH) to check levels of the parathyroid hormone before and after removing the abnormal gland. It many cases this information can help confirm that all the abnormal parathyroid tissue has been located and removed.
Patients who are candidates for the MIRP procedure usually go home within a few hours of the procedure. They may return to work the next day and are seen in the office for followup in one week. Those patients who have negative scans may require a longer operation, one to three hours, and may be asked to spend the night in the hospital to be discharged the following morning. Also those patients that have associated thyroid disease requiring operative treatment at the same time usually spend one night in the hospital.
Inherent in all parathyroid surgery are remote risks (1%) including hoarseness related to the proximity to voice box nerves to the parathyroid tissue. Low calcium levels may occur for a few days and are treated with oral calcium supplements for the first week. Persistent low calcium that requires treatment is rare (1%). Complications common to all surgeries such as infection or postoperative bleeding are rare (1%). Despite our best efforts, in approximately 1% of patients we are unable to locate the diseased gland (usually due to an ectopic location of the gland) and the patient has persistent hyperparathyroidism.
Our Surgeons have extensive experience in parathyroid surgery. If you have been diagnosed with hyperparathyoidism, we would be happy to evaluate your case and help determine if surgery is right for you. For more information and to schedule an appointment, please contact our office.