Endocrine Head & Neck Surgery

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Parathyroid Disorders/Hyperparathyroidism & Treatments

What is Hyperthyroidism?

The most common problem related to the parathyroid glands is a condition called primary hyperparathyroidism. Many patients are first diagnosed with primary hyperparathyroidism when routine blood tests show abnormally high levels of calcium in the bloodstream.  The diagnosis is confirmed when subsequent testing shows a high level of parathyroid hormone (PTH), a hormone secreted by the parathyroid glands, in their blood. The parathyroid glands are tiny but potent, distinct glands located adjacent to the thyroid gland, whose function is very different than that of the thyroid. When the endocrine system functions normally, the parathyroid glands regulate calcium levels in the bloodstream even when oral intake of calcium in food or vitamins may be high or low. Calcium is necessary in the circulation to maintain normal muscle and nerve function.

However, primary hyperparathyroidism occurs when one or more parathyroid glands become enlarged and independently produce excess PTH. In this situation, the bones, where calcium is stored, are stimulated to release excess calcium into the blood stream.  The result is hypercalcemia (high calcium levels in the blood). Primary hyperparathyroidism can lead to a number of medical issues and symptoms including kidney stones, bone pain, osteoporosis (loss of bone mass), and mood disorders. When hyperparathyroidism is diagnosed, if sufficiently severe, then surgery is recommended. There is no medication to cure hyperparathyroidism, and the curative treatment is surgical removal of the abnormal gland(s).

If parathyroid surgery is being considered, effort is made to localize the responsible gland or glands so that it/they can be removed in as minimally invasive a manner as possible. In most cases, only one of the parathyroid glands is enlarged, in a benign growth – that is, not cancer – called a parathyroid adenoma. In some patients benign enlargements occur in more than one parathyroid gland at the same time, a condition called parathyroid hyperplasia. Very rarely (in 1% of cases), enlargement of a parathyroid gland is due to cancer. Localizing studies include ultrasonography, sestamibi parathyroid scanning (a nuclear medicine/radiology study), and sometimes CT scanning of the neck and upper chest. Since parathyroid glands can sometimes be ectopic, or located away from the usual position adjacent to the thyroid gland, it is ideal for the parathyroid surgeon to have as good an idea as possible of the location of the suspected abnormal parathyroid gland(s) before proceeding with surgery to remove these gland(s).

Diagnosis

The diagnosis of hyperparathyroidism is typically made with blood tests. Many patients first become aware of high calcium levels on routine bloodwork, and subsequent testing shows an elevated level of parathyroid hormone (PTH). Additional labs may be ordered to check your level of Vitamin D or to look at the amount of calcium in your urine. 

Once hyperparathyroidism has been confirmed, the next step is to locate the gland or glands that are causing the problem. You will likely undergo a nuclear medicine study called a Sestamibi scan, as well as a neck ultrasound. Occasionally, a CT scan may be performed instead or in addition.

Sestamibi parathyroid scan (right) showing a bright signal in the right side of the neck at the site of a parathyroid adenoma.

Treatment

Patients with hyperthyroidism are always initially treated with antithyroid drugs (methimazole and/or PTU), which work to inhibit thyroid hormone. Although very effective, antithyroid medications are often needed for long periods of time to achieve remission. Sometimes beta-blockers are also prescribed to initially control the symptoms related to hyperthyroidism.  

More definitive treatment options for hyperthyroidism include radioactive iodine therapy or surgery. Radioactive iodine therapy is used to destroy thyroid tissue and can be very effective in achieving a cure for some patients.  Patients with eye problems in Graves’ disease and those with compressive symptoms are often not ideal candidates for this approach.  

Surgical treatment for hyperthyroidism may be considered if there are co-existing thyroid nodules, known eye disease, and/or a preference to avoid radioactive iodine. In patients with Graves’ disease or toxic nodular goiter, the entire thyroid gland is usually removed. In patients with a solitary toxic nodule, the surgeon can often remove only half of the thyroid.

Parathyroid surgery

Surgery is the definitive treatment for primary hyperparathyroidism. The physician will first want to identify where the enlarged gland(s) are located in the neck through imaging studies prior to surgery. Most patients have one enlarged gland (adenoma), but some patients may have multiple enlarged glands (hyperplasia). Although the position of the parathyroid glands is relatively constant, on occasion these glands are sometimes located in unexpected areas in the neck. The studies usually include a nuclear medicine scan (sestamibi scan) and an ultrasound. In some instances, CT scanning maybe necessary to locate the gland. In some instances, CT scanning may be necessary to locate the gland. These proactive measures often cut down on the time and extent of the surgery.

Parathyroid surgery is generally performed though a small incision in the front of the neck, with an excellent cosmetic result. Some patients stay overnight, but most are discharged on the same day as surgery. Recovery is fairly quick, with most patients transitioning back to work and returning to their normal routines within 7-10 days. When performed by an experienced endocrine surgeon, the operation is successful in approximately 95% of cases. 

 

What will Happen in Surgery?

You will be given general anesthesia to put you to sleep. You are positioned with special pillows under your neck to tilt your head back. An incision is made at the base of your neck and is about two to four inches long, depending on the exact type of operation you have. Using magnifying lenses, the surgeon locates the parathyroid glands and the abnormal one(s) are removed. The incision is stitched closed and is then covered with steri-strips (tapes) and a dry gauze dressing.

The operation generally lasts from 1 to 3 hours. After surgery, you will stay in the recovery room for several hours. Depending on the exact type of surgery you have you will either be discharged home on the same day of surgery or be admitted for one night’s stay.

 

How will I Feel After Surgery? 

Your calcium level may drop after surgery, because your remaining parathyroid glands have not functioned fully in a long time. If you experience numbness or tingling around your mouth or in your fingertips (within 24-48 hours generally), take calcium supplements (about 1200 mg) every four hours for these symptoms and until the symptoms resolve. Once the symptoms have resolved, discontinue the calcium supplement. Should they reoccur, begin taking the calcium supplement again. If you have any questions, please contact your surgeon.