HYPERPARATHYROIDIS

M
FAISAL GHANI SIDDIQUI
MBBS; FCPS; PGDIP-BIOMEDICAL ETHICS; MCPS-HPE

PROFESSOR OF SURGERY
JINNAH SINDH MEDICAL UNIVERSITY
PREAMBLE
• Anatomy & physiology of the parathyroid glands
• Hyperparathyroidism
 ANATOMY &
PHYSIOLOGY
OF THE
PARATHYROID
GLANDS
PARATHYROID GLANDS -ANATOMY

• Endocrine glands
• Situated behind thyroid gland
• 4 in number
• Superior glands constant in
position and number
• Inferior glands may;
• Vary in position
• May be more than two in number
(supernumerary)
 PARATHYROID GLANDS -FUNCTION

PARATHORMONE
CHIEF CELLS
PARATHYROID (PTH)
GLANDS
OXYPHIL CELLS
INCREASED
CALCIUM LEVEL
IN BLOOD
PARATHORMONE -EFFECTS ON CALCIUM

• Enhances calcium release from bones by stimulating

osteoclasts
• Increases calcium absorption from distal tubules of
kidneys
• In kidneys, converts 25-hydroxy vitamin D into 1,25-
dihydroxy vitamin D. This absorbs calcium from
intestine
• Increases phosphate secretion by the kidneys
 HYPER-
PARATHYROIDISM
HYPERPARATHYROIDISM
-increased production of
parathormone (PTH) leading to
hypercalcemia
HYPERPARATHYROIDISM -CAUSES

• Primary
• Secondary
• Tertiary
PRIMARY HYPERPARATHYROIDISM
HYPERPLASIA
ADENOMA
CARCINOMA

INCREASED SECRETION
OF PTH &
HYPERCALCEMIA
PRIMARY HYPERPARATHYROIDISM

HYPERPLASIA
ADENOMA
CARCINOMA

INCREASED
PRODUCTION OF
PTH
 SECONDARY HYPERPARATHYROIDISM
CHRONIC RENAL FAILURE

REDUCED CONVERSION OF 25-DHCC

TO 1, 25-DHCC

REDUCED ABSORPTION OF CALCIUM

FROM GUT

CHRONIC HYPOCALCEMIA

PARATHYROID HYPERPLASIA & INCREASED

SECRETION OF PTH
 TERTIARY HYPERPARATHYROIDISM
CHRONIC RENAL FAILURE
REDUCED CONVERSION OF 25-
DHCC TO 1, 25-DHCC
REDUCED ABSORPTION OF
CALCIUM FROM GUT
CHRONIC HYPOCALCEMIA

PARATHYROID HYPERPLASIA &

INCREASED SECRETION OF PTH

AUTONOMOUS AFTER RENAL

TRANSPLANTATION
HYPERPARATHYROIDISM
-BIOCHEMICAL CHANGES
• Raised PTH level
• Increased serum calcium
• Decreased serum phosphate
• Hypercalciuria
HYPERPARATHYROIDISM
-CLINICAL FEATURES
 HYPERPARATHYROIDISM
-CLINICAL FEATURES
BONES, STONES, ABDOMINAL GROANS,
& PSYCHIC MOANS
HYPERPARATHYROIDISM –CLINICAL
FEATURES
• Bones: short stature, bone deformities, abnormal
curvature of spine; multiple cysts in jaw, skull,
middle phalanges;
• Stones: stones; nephrocalcinosis
• Abdominal groans: peptic ulcer, pancreatitis
• Psychiatric symptoms: mood disturbances,
apathy, fatigue, failure to concentrate
Scoliosis: abnormal curvature
of the spine
Multiple cysts in
the mandible
Plain X-ray skull: multiple
cysts
(salt-pepper appearance)
X-ray of humerus and hand:
‘peudotumours’ -osteitis
fibrosa cystica
multiple cysts in hand
bones
Stone in
left kidney in a patient with
hyperparathyroidism
Stone in
left kidney
HYPERPARATHYROIDISM
-INVESTIGATIONS
INVESTIGATIONS

• Total serum calcium

• Inappropriate (elevated or normal) PTH levels in the
presence of high serum calcium
• Hypophosphataemia
• Elevated urine calcium
HYPERPARATHYROIDISM
-MANAGEMENT
Surgery is the only curative option!
Medical therapies offered in mild cases to make calcium
levels suitable for surgery
MEDICAL TREATMENT

• Low calcium diet

• Withdrawal of drugs (diuretics) that aggravate
hypercalcemia
• Calcium reducing agents (biphosphonates)
• Calcium receptor agonist (cinacalcet)
INDICATIONS FOR PARATHYROIDECTOMY

• Urinary tract calculi

• Reduced bone density
• High serum calcium
• Age < 50 years
• Deteriorating renal function
• Symptomatic hypercalcemia
PREOPERATIVE LOCALIZATION OF
GLANDS
• Surgery has high recurrence rate because surgeon
fails to identify:
• an ectopic adenoma not accessible through a cervical
incision
• disease may involve multiple glands

• Glands therefore should be routinely visualized

preoperatively
PREOPERATIVE LOCALIZATION OF GLANDS -HIGH
FREQUENCY NECK ULTRASOUND

• 75 % of enlarged glands
identified
• Non-invasive
• Cannot visualize
mediastinum
• Ineffective in the presence
of nodular goitre
Ultrasound scan of parathyroid adenoma at upper pole right thyroid lobe. C,
carotid artery; A, parathyroid adenoma; T, right thyroid lobe.
TECHNETIUM-99m-LABELLED SESTA MIBI
ISOTOPE SCAN
• Identifies 75 % of abnormal glands
• Scans mediastinum
Technetium-sesta mibi scans 15 minutes and 3 hours after injection showing retention of isotope in a
left inferior parathyroid adenoma
Mediastinal parathyroid adenoma. (a) Preoperative sestamibi scan with mediastinal adenoma (arrowed). (b) Operative
photograph of median sternotomy showing a 4-cm parathyroid adenoma
OPERATIONS

• Incisions:
• Targeted small incision approach
• Bilateral neck exploration using thyroidectomy
incision
• Preoperative injection of technetium-
Targeted parathyroid surgery; a 2-cm
labelled sestamibi and use of gamma incision over left inferior parathyroid
adenoma
probe to guide exploration
• Intraoperative PTH measurement to
confirm that the source of excess PTH has
been excised