There are between 4 to 8 parathyroid glands which sit either side of the thyroid gland in the base of the neck. Their job is to regulate the level of calcium in the blood. Calcium is an important chemical in the body that helps muscles contract.
The calcium level in the blood can increase in some people. This causes side effects such as depression, kidney stones, abdominal pains, tiredness, thirst, constipation, brain fog and osteoporosis. There are many causes for a high calcium level in the blood. One reason is that a benign swelling develops in one or more parathyroid glands – a parathyroid adenoma. This secretes more parathormone which pulls calcium out of the bones and dumps it into the blood stream.
Patients are often referred to me with a high calcium level by an endocrinology doctor that suspects a parathyroid adenoma. When you come to see me, I would ask about your symptoms, your past medical history, any family that have had a similar problem (some syndromes such as Multiple Endocrine Neoplasia 1 can cause this), allergies and medications. I would examine your throat, nose, neck and use a camera in the nose (nasendoscope) to check your vocal cords are moving. The nerves that move the vocal cords (recurrent laryngeal nerves) sit next to the thyroid and parathyroid glands. You normally would have a calcium and parathormone blood test.
Scans are often necessary to identify if there is a parathyroid adenoma, in the neck, and where it is. I often use ultrasound, SPECT, and 4DCT to identify these swellings. I use these investigations as a map for surgery, as finding these parathyroid adenomas in the neck is a bit like finding a needle in a haystack. Most patients have surgery (parathyroidectomy) to remove the offending gland, but if you are not fit enough for surgery long term medication (cinacalcet) and drinking plenty of water brings down the calcium level in the blood.
Minimally Invasive Parathyroidectomy
This operation is largely preventative i.e. to prevent osteoporosis and subsequent bone fractures, or can be used to treat symptoms or side-effects such as brain fog, depression or kidney stones. It involves coming into hospital, having a general anaesthetic (fully asleep). When you are asleep, I make a small 3-4cm incision on the side of the neck where the parathyroid gland has been identified. If there are glands on both sides of the neck, I use a midline incision. I dissect out the muscles of the neck and pull them to one side. I look for the carotid artery and, next to this, I look for the offending gland. It often appears dark and bleeds on contact. I gently remove the surrounding tissue and blood vessels from the gland and put it into a pot to send away for analysis under the microscope to confirm the diagnosis. It takes 2 to 3 weeks for the results to come back. I stitch the wound up with absorbable sutures. The wound is raised and red on purpose, and after a few months will flatten out and should be barely visible. I often hide the wound in a skin crease. I put glue on top to make it waterproof, so you can shower. The operation normally takes 15 to 60 minutes. You will have blood tests to check that your calcium level is dropping after surgery (a sign of success). If the calcium has come down, I normally prescribe 4 weeks of calcium tablets to make sure the calcium level in the blood does not plummet. You will often stay overnight for observation. You will be discharged the next morning and need 2 weeks off work afterwards, at home, to prevent a wound infection.
The risks of the surgery are: pain, infection, bleeding, general anaesthetic complications, collection of blood or fluid under the surface of the skin, low calcium requiring calcium replacement tablets for life (uncommon), further surgery if the calcium remains high, damage to the recurrent laryngeal nerve causing hoarseness of voice (rare), damage to the surrounding structures such as oesophagus or trachea, and 20% risk of mortality if COVID positive during a general anaesthetic. If you have contracted COVID, it will result in a 7 week delay to surgery. I see you a few weeks after surgery to check all is well. This is often preceded by a blood test to check the calcium and parathormone levels have come down. I use a nasendoscope to check the vocal cords are still moving after surgery, and that I have preserved the recurrent laryngeal nerves.