See below for some information regarding primary hyperparathyroidism:
The parathyroid glands are tiny glands that produce the parathyroid hormone (PTH), regulating the calcium in our body. They are usually 4, but sometimes they can be less that 4 or more than 4. Their usual location is behind the thyroid gland, but sometimes they are not in their usual location and can be seen anywhere in the neck or upper chest, or sometimes even inside the thyroid gland.
Hyperparathyroidism is a condition where there is increased production of parathyroid hormone. It is classified as:
Primary hyperparathyroidism. This is caused when there is excessive unregulated production of parathyroid hormone leading to hypercalcemia, by one or more parathyroid adenomas (benign tumor of the parathyroid), 4-gland parathyroid hyperplasia, or very rarely parathyroid carcinoma (this is exceedingly rare).
Secondary hyperparathyroidism. This is a “reaction” of the parathyroids, when they sense that calcium or vitamin D intake is lower than required, or when phosphorus level is higher than required (such as in patients with chronic kidney disease). In those cases, the parathyroid hormone is elevated but the calcium is not high or very close to the upper limit of normal, and treatment usually consists of calcium and/or vitamin D replacement.
Tertiary hyperparathyroidism. This is a rare condition, in patients with advanced chronic kidney disease, where sometimes chronic secondary hyperparathyroidism over the years can cause the parathyroid glands to lose their ability to regulate calcium and eventually cause hypercalcemia.
It is very important to classify hyperparathyroidism correctly, as treatment of each form of hyperparathyroidism is completely different depending on if it is primary, secondary, or tertiary hyperparathyroidism. In addition, it is very important to accurately diagnose primary hyperparathyroidism and rule out a condition called Familial Hypocalciuric Hypercalcemia, prior to proceeding with treatment.
The symptoms of primary hyperparathyroidism are several, and many times non-specific, and include fatigue, “brain fog”, mood changes, difficulty concentrating or changes in cognition, sleep disturbance, muscle cramps or pain, bone pain, dysuria, nausea, heartburn, increased urination. Severe hypercalcemia or hypercalcemic crisis can lead to cardiovascular complications, severe confusion, coma, severe dehydration, acute kidney injury, pancreatitis, arrhythmia.
Surgery is recommended for primary hyperparathyroidism when certain criteria are met, such as history of kidney stones or chronic kidney disease, osteoporosis or fragility fracture, very high calcium levels, age younger than 50 years old, presence of symptoms, etc.
Prior to surgery, it is highly recommended to do imaging tests for parathyroid localization. These can include neck ultrasound, sestamibi scan, 4D-CT scan, or other scan as clinically indicated. Identifying the abnormal parathyroid gland(s) preoperatively has many benefits, as it decreases the length of surgery, increases the chance of success of surgery, etc. Our endocrinologists are very experienced in parathyroid ultrasound and have very high parathyroid localization rates!
Even if parathyroid localization efforts fail to identify an abnormal parathyroid gland, surgery can still be done by the traditional approach of parathyroidectomy with 4 gland exploration.
It is important to note that when parathyroidectomy is considered, the thyroid gland needs to be evaluated concurrently as well. Testing the thyroid function and evaluating the thyroid with an ultrasound is very important. This way, if there is any thyroid condition for which thyroid surgery is indicated, such as thyroid cancer, thyroid surgery can be done at the same time as the parathyroidectomy.
