What is Parathyroid?
As described above, parathyroids are endocrine glands. There are usually four tiny parathyroid glands, each a few millimeters in size, hidden near or inside the thyroid gland in the neck. They produce and release parathyroid hormone which controls the calcium levels throughout the body.

What is Hyperparathyroidism?
Hyperparathyroidism is excess production of parathyroid hormone (PTH) by abnormal parathyroid gland(s) in the neck

What are its manifestations? What happens in Hyperparathyroidism?
Kidney stones, bone pains, bone cysts and swellings, joint swellings, peptic ulcer pain made worse by antacids, weakness, fatigue, and depression can be due to hyperparathyroidism.

What causes Hyperparathyroidism?
It is usually due to a non cancerous growth called Adenoma.
It can be due to increase in size of all the parathyroid glands called hyperplasia. When hyperplasia occurs independently it is called Primary hyperplasia. When it occurs due to calcium disturbances, as seen in prolonged renal failure, it is called Secondary hyperplasia. Later when it becomes independent, it is called Tertiary hyperplasia. Rarely, it may be due to parathyroid cancer

How do you test for it?
This can easily be detected by checking blood for serum calcium and PTH (Para thyroid hormone), both of which will be abnormally high. It can then be localized by ultrasound scan and Technetium Tc 99m Sestamibi scan (See Image).

Why is treatment important?
Left untreated bones become weak and break easily. Kidney stones keep growing and reforming after removal, ultimately damaging the kidneys.

How is Hyperparathyroidism treated?
Treatment requires surgical removal of the abnormal parathyroid gland(s). Usually there is a single parathyroid adenoma and it needs to be identified and removed (Parathyroidectomy). Occasionally there may be more and these need to be detected and removed. If one adenoma is dominant, other adenomas may become obvious later.

If there is hyperplasia, all glands except half a parathyroid gland are removed. It is preferable to transplant this half into an easily assessable muscle in the neck or forearm so that if it grows excessively, parts of it can easily be removed.

For parathyroid cancer, the adjacent half of the thyroid gland is removed (Hemi Thyroidectomy) in addition to the parathyroid cancer.

What are the types of anesthesia and surgery for parathyroid adenoma removal?
Parathyroid surgery can be done under local, regional or general anesthesia.

Traditionally a large 7 to 10cms cut is made across the neck and the entire front side of the neck is searched for these four tiny parathyroid glands by an experienced surgeon. The Technetium Tc 99m Sestamibi scan (a radio-isotope scan) has revolutionized the identification and treatment of abnormal parathyroid glands. The use of this radio-isotope scan and the ultrasound scan has made minimal surgery possible for parathyroid adenoma. There are many methods of minimally invasive/ endoscopic surgery for the removal of parathyroid adenoma. These techniques (totally endoscopic, video assisted and radio guided) have been demonstrated to be feasible and safe, but it depends on the surgeon to obtain the best results with these approaches. The surgery can be done through a single cut less than 3 cm or through three to four 5mm cuts in the armpit and breast. A specialist endoscopic & endocrine surgeon (a rare species!) would be conversant with all the open and endoscopic methods and offer you all the possible options. ENT/ Head & neck surgeons, surgical oncologists, general surgeons, laparoscopic surgeons also operate on the parathyroid gland(s), each by the method they are familiar with.

Complications are rare under the expert care of an experienced endocrine surgeon. The success of the procedure can be determined soon after and the patient is fit to go home in a few hours though we advise our patients to stay till the calcium levels stabilize a bit. Outstation patients are treated on a priority basis.

What are the risks of parathyroid surgery?
Possible risks include: 1) bleeding, 2) infection 3) hoarseness due to injury to the speech (recurrent laryngeal) nerve, and 4) rapid fall in calcium levels. The overall risk of complications should be <2% with an experienced surgeon.

What can I do before parathyroid surgery to be optimally prepared?
It is important that you do not eat or drink anything after midnight the night before surgery. Continue to take all important medications such as heart, asthma, or blood pressure medicines as advised by your anesthesiologist with a small sip of water on the morning of surgery. Diabetic medicines are not taken by mouth on the day of surgery. Do not take blood thinning drugs or aspirin for 7-10 days prior to your surgery date. Be careful to avoid a fall as your bones will be brittle. Quit smoking.

Will I have pain? Will I have stitches? What can I expect after surgery?
You will be asleep during your surgery and will feel no pain. Pain after surgery is easily suppressed by prescribed medicines. Stitches placed under the skin are not visible and dissolve after a period of time and do not need to be removed. You might have a sore throat, difficulty swallowing, or a slightly hoarse voice after the operation. These conditions will resolve with time. Once you are fully awake, you will be moved to a bed in a hospital room where you will be able to eat and drink as you wish. Near normal activity can begin on the first day after surgery. You may have some difficulty with full range of movement of your neck for a week after surgery. You can return to work in a few days time but be careful with your brittle bones. Vigorous activities and sports should be delayed as the bones weakened by the parathyroid problem take time regaining there strength. You may experience low blood calcium (hypocalcaemia). You will need to take calcium and vitamin D tablets. During your follow-up visit, your Calcium levels will be checked and medication dose adjusted accordingly.

What are the signs of low blood calcium and how will I know if I need to take extra calcium?
Symptoms of low blood calcium include numbness and tingling in the fingers and around the mouth, weakness, headaches, muscle cramps, intestinal cramps, heart arrhythmia (rhythm disturbance). Low blood calcium can be prevented or treated with extra calcium intake.

Left untreated, very low calcium levels can cause chocking.

Will I have a scar?
All surgeries cause some scarring. When performed by a skilled endocrine surgeon, the parathyroid operation will be performed using the smallest, cosmetically placed incision possible. Plastic surgery type closures are used to minimize scarring. Ultimately the type of scar formed depends mostly on the type of your body response to any injury. The majority of people having parathyroid surgery have minimal scar present by 6 months after surgery