WHAT ARE THE PARATHYROID GLANDS?
The parathyroid glands are four tiny glands, located in the neck, that control the body’s calcium level. A normal parathyroid gland is about the size of a grain of rice and weighs approximately 30mg. Some patients have less or more than four glands, but most patients have four – 2 on the right and 2 on the left. The parathyroid glands produce a hormone called parathyroid hormone (PTH).
WHAT IS HYPERPARATHYROIDISM, AND WHY IS IT A PROBLEM?
Primary hyperparathyroidism is an excess of parathyroid hormone in the bloodstream, most commonly due to an abnormal overactivity and enlargement of one or more of the parathyroid glands. These enlarged glands are almost always benign growths and are only cancerous in very rare cases. Hyperparathyroidism leads to high levels of calcium in the blood (hypercalcaemia), which can cause a variety of health problems including:
reduction in bone density leading to fragile bones, osteoporosis and fractures
excessive urination and dehydration
abdominal pain from ulcers, constipation and pancreatitis
fatigue and tiredness
depression or forgetfulness
bone and joint pain
nausea, and loss of appetitie
feeling generally unwell without apparent cause
worsening cardiovascular disease
Many patients with hyperparathyroidism do not experience these symptoms, especially when the disease is mild, and are diagnosed incidentally when a high calcium reading is noticed on a blood test. The damaging and detrimental impact of hyperparathyroidism on your body occurs over a long timeframe, and so we recommend treatment of this problem in most patients, even if apparently asymptomatic. There is also much evidence that patients report a higher quality of life after treatment for hyperparathyroidism.
Secondary hyperparathyroidism refers to high parathyroid hormone levels because of other diseases which affect the function of the parathyroid glands. The most common causes are vitamin D deficiency and chronic renal failure.
WHAT IS THE TREATMENT FOR PRIMARY HYPERPARATHYROIDISM?
Some patients with very mild disease might not require treatment and can simply be monitored. In patients who are recommended for treatment, the only effective option for cure is a parathyroidectomy, which is surgical removal of one or more of the enlarged glands causing the abnormal overactivity. Surgery will provide a cure in about 95% of all cases.
WHAT WILL HAPPEN DURING MY CONSULTATION FOR MY PARATHYROID PROBLEM?
Your consultation will begin with a careful history and physical examination, followed by review of your results including blood tests and scans. A bedside office ultrasound will be conducted to provide real-time diagnostic information, and to find the abnormal parathyroid. A nasendoscopy (thin fibre-optic camera procedure via the nostril) may be performed under local anaesthesia to examine the function of your vocal cords. Further investigations including blood and urine tests, and additional scans, may be recommended. Treatment options will then be discussed and you will have the opportunity to ask questions in order to make the best decisions for your care.
HOW IS PARATHYROIDECTOMY PERFORMED?
There are generally two types of parathyroid operations that are performed – either a minimally invasive parathyroidectomy (MIP) or a four gland exploration. In most patients with only one abnormal gland, a minimally invasive procedure is performed through a 2-3cm incision. In other patients with more than one abnormal gland, or if the location of the abnormal gland is not clear, a four gland exploration through a larger 5-6cm incision is required. The operation is performed under a general anaesthetic, and the duration can vary widely depending on whether minimally invasive or a four gland exploration, but usually takes on average 1-1.5 hours. During the operation we have a pathologist on standby who immediately analyses the excised specimens to confirm the successful removal of the abnormal parathyroid gland(s). The parathyroid level is then checked immediately after the surgery, and in most patients cure is quickly confirmed. Most patients stay in hospital for one night, and have minimal pain.
ARE THERE COMPLICATIONS FROM PARATHYROIDECTOMY?
Complications from parathyroidectomy are uncommon. Risks include general anaesthesia (e.g. cardiac or respiratory problems), bleeding, infection and very occasionally problems with the recurrent laryngeal nerves which are important nerves that are close to the parathyroid glands and control the vocal cords. We use intraoperative nerve monitoring to help identify and protect the recurrent laryngeal nerves during thyroidectomy, and also wear high-magnification loupes which aids both nerve and parathyroid gland identification.
In some patients, the body’s calcium level can become low after the surgery for a temporary period, as your bones absorb calcium from the bloodstream now that the effect of the abnormal parathyroid growth has been removed (‘hungry bone syndrome’). This is usually temporary, but may require calcium supplements for a week or two until the situation has stabilised and the other normal parathyroid glands regain function.
The risk of failure to cure the hyperparathyroidism with surgery is around 5% and can occur as a result of another abnormal parathyroid gland which has not been identified on scans or during the surgery. In this situation, further scans and surgery might be required.
The best way to optimise the likelihood of success with parathyroid surgery is to be treated by a high volume endocrine surgeon who specialises in parathyroid surgery.
WHAT IS THE RECOVERY LIKE AFTER PARATHYROIDECTOMY?
Recovery after parathyroidectomy is usually straightforward. Most patients have minimal pain, eat and drink normally and return to work within 1 week, although we have had patients return to work within 48 hours. Light duties are preferable for 2 weeks after surgery. Further advice regarding recovery in your specific circumstances will be discussed during the preoperative consultation.