Parathyroid Glands

They are 4 little glands in your neck, next to the thyroid gland. Each is usually the size of a grain of rice. 

Their only job is to control levels of calcium in our body. Calcium is an important substance that we need for our nerves and muscles to work properly and for our bones to remain strong. Parathyroid glands secrete a substance called Parathyroid hormone which controls the amount of calcium in our blood. If our blood levels are low the hormone is released to increase blood calcium levels. It does this by increasing the absorption of calcium from the food we eat and taking calcium from our bones. 

In some people one or all four glands start over working and producing too much parathyroid hormone. We don’t know why this happens. The effect of too much parathyroid hormone in the body is to increase calcium levels in the blood by increasing absorption of calcium from the food you eat and releasing it from the stores in your bones.  This is called primary hyperparathyroidism.

In the majority of patients, this is a problem with one gland over working (80% of people), which is called a parathyroid adenoma, but in the other 20% it is due to all four glands over working, which is a process called hyperplasia. This is a benign process ie. not cancerous.

Very, very rarely, primary hyperparathyroidism can be caused by a cancer in one of the parathyroid glands.

This is a disease often seen in patients with kidney failure. As your kidneys don’t work well, you excrete too much calcium in your urine. As a result your parathyroid glands are constantly stimulated to produce more parathyroid hormone.

This situation arises when patients have had long standing secondary hyperparathyroidism. After a while, the glands continue to produce high levels of hormone, even though the stimulus of low blood calcium no longer exists. This is usually seen in patients who have had a successful kidney transplant, and so have normal blood calcium levels again, but the glands have not learnt to switch off again.

The symptoms are related to having a high level of calcium in your blood but are often thought of as just some of the signs of aging in older patients.

Nerves

Calcium is need for nerves to work properly so high levels can cause:

• Confusion
• Forgetfulness
• Depression

Muscles

Calcium is needed for muscles to work properly so high levels can cause:

• Weakness
• Overwhelming tiredness

Bones

Calcium is needed to keep bones strong so high levels can cause:

• osteoporosis (thin, weak bones)
• fractures (broken bones, often with very little force)
• bone pain

Others

There are a range of other symptoms associated with high calciums:

• excessive thirst
• needing to pass water more frequently
• kidney stones
• pancreatitis (inflammation of your pancreas gland)
• stomach ulcers and acid reflux

If your endocrinologist or GP thinks that you have over active parathyroid glands they may refer you to us for further investigation and treatment.

The diagnosis of hyperparathyroidism is made on blood tests to measure the level of hormone and calcium in your blood. In order to confirm the diagnosis we may need to test your levels of Vitamin D and perform a test on your urine also.

You may also have to undergo other tests such as a DEXA scan to diagnose osteoporosis or other conditions that your high calcium may have caused.

After you are referred to us we will arrange for two scans which will help us decide on whether this is a one gland or a four gland problem

MIBI scan

This scan involves the injection of a substance that is taken up by the parathyroid glands. It takes a couple of hours to perform.

USS scan

This is a scan, like the one that pregnant women undergo but of the neck. It is painless and quick.

We aim to perform both of these scans on the same day.

CT scan

Although the parathyroid scans are usually in the neck, they can occasionally be found in your chest and sometimes we have to do other scans to locate them before we consider an operation.

The only treatment of hyperparathyroidism is an operation. However, if your disease is very mild or you are not fit to undergo a general anaesthetic the risks of surgery may outweigh any benefits and surgery may not be the best option for you. When we meet you in the outpatients department we will ask you about your symptoms and medical history and will review your scans and blood test. We will then discuss with you the best options for you.  

Before you undergo surgery you will need to have the following:

1. Meeting with a surgeon to discuss your case and make a decision about surgery
2. Pre-operative assessment to check that you are fit to undergo an operation. This will include taking a full medical history from you, listening to your heart and lungs and measuring your blood pressure.
3. A check of your vocal cords. One of the potential complications of surgery on your parathyroid glands is injury to the nerves to your voice box/vocal cords. Therefore, everyone has to undergo a small telescope test up the nose to look down at the vocal cords and check that they are working properly. This takes just a few minutes, and is pain free. 

cTo undergo this operation you must first be put to sleep completely, ie. a general anaesthetic. We then make a small incision at the lower part of the front of your neck and search for your parathyroid gland/glands. We will be guided by the USS and MIBI scans as to which glands we will look at and which we will remove. This will have been discussed with you prior to surgery.  At the end of the operation we will stitch up your skin with dissolvable stitches so there will be nothing to be removed. We will inject local anaesthetic before you wake up to make you as comfortable as possible.

Possible complications

These can be divided those associated with the actual operation and those with receiving a general anaesthetic.

Surgical:

1. Infection – this is a fairly quick healing and clean part of the body so infections are not common. However, if your wound becomes red, sore or mucky after you return home then you should contact your GP who can decide if it is infected or not.
2. Bleeding – the worst bleeding most patients get is a bit of bruising which resolves with time. Bleeding that requires another operation can happen but is rare. If it does happen, it is usually apparent before you are discharged
3. Scar
4. Stiff neck – this is fairly common, but usually temporary.
5. Nerve injury -there is a nerve that supplies your voice box that runs very near the parathyroid glands. This can be injured during the operation, giving you a hoarse voice. This is a temporary problem in 1 in 100 operations and permanent very rarely (1 in 1000 case). Most patients wake up with a sore throat and a hoarse voice from the anaesthetic tube and the surgery so do not worry if this is the case.
6. Low calcium levels – Behind the thyroid gland sit 4 parathyroid glands. These control the levels of calcium in your blood and can become injured during thyroid surgery. This results in a low blood calcium level which can cause symptoms such as pins and needles in your fingers/toes and around your mouth. We will be monitoring your blood calcium levels but if you develop any of these symptoms after surgery you should tell a doctor as soon as possible as you may need to take calcium tablets for a short period following thyroid surgery.
7. Need for further surgery – In a small number of cases a further operation is needed to completely treat your hyperparathyroidism.

Anaesthetic:

Possible complications after this operation include:

1. Sore throat
2. Feeling sick or actually vomiting
3. Dizziness from low blood pressure
4. Damage to teeth (this is very rare)

You will have an opportunity to talk to the anaesthetist on the day of surgery.

You need to remain in hospital, usually just overnight. You may experience some pain, but this can usually be well controlled with simple tablet painkillers such as paracetamol and codeine phosphate. You may need to take these for a few days after the operation. Whilst you are in hospital, we will repeat blood tests for your hormone levels and blood calcium levels. Most patients can go home by lunch time the next day. 

Blood tests

You should have your calcium levels checked with a blood test by your GP within a week of your discharge.

Wound care

Your skin will have been closed with dissolvable stitches and covered with a small dressing. This can be easily removed after 3 or 4 days. It is normal for there to be some swelling in the area, which becomes slightly firm. If you are concerned about your wound you should see your GP.

Once the wound is healed over and you are able to comfortably touch your neck you can start to gently massage it E45 Cream or Bio oil.

Pain killers

Most people find that they need to take simple tablet painkillers such as paracetamol and codeine phosphate for a few days after surgery.

Driving

We advise you to avoid driving for a couple of weeks until you can comfortably turn your neck from side to side without any pain.

Talking and Singing

We recommend that you take a couple of weeks of work following this operation. This allows you to rest your voice, with no singing or shouting. 

We like to see you in outpatients 2-4 weeks after your operation to check that all has gone well with your recovery. Usually, we discharge you back to the care of the person who referred you to us (GP, endocrinologist or kidney specialist) at this stage.