Michel Babajanian, MD, FACS
Otolaryngologist & ENT located in Century City, Los Angeles, CA
Hyperparathyroidism is a serious condition where your parathyroid gland produces too much parathyroid hormone. This is the hormone that balances bone-building calcium levels in your body. But when you have too much of it, your calcium levels surge to dangerous levels -- called hypercalcemia -- and it is critical for you to see a specialist like board-certified otolaryngologist and ENT Dr. Michel Babajanian, who serves Century City, California. With his extensive background in thyroid disorders and modern surgical treatment techniques, Dr. Babajanian will put you back on a path to good health.
Parathyroid Surgery Q & A
Parathyroid glands are typically four separate very small endocrine glands that are located very close to the thyroid gland in the lower midline portion of the neck (hence they derive their name as "parathyroid", being next to the thyroid gland). These glands produce a very tightly regulated hormone, which controls the levels of the calcium in the bloodstream. Calcium is a vitally important element that participates in many vital functions of the body including muscle contraction and many other important chemical reactions necessary for life. Sometimes, some of the parathyroid glands become hyperactive (hyperplasia) or grow a non-cancerous tumor, called adenoma, which produce excessive amount of the hormone, thus creating elevated levels of calcium in the bloodstream at the expense of depleting the bones (which are the reservoir of calcium in our bodies) causing rapidly progressive osteoporosis (weak and fragile bones). The excessive calcium causes many problems in the body including kidney stones, psychological disease such as depression or psychosis, high blood pressure, abdominal pain and other anomalies. In those situations, the abnormal gland or glands need to be removed surgically. Our surgeons perform the state of the art, minimally invasive parathyroidectomy utilizing state-of-the-art technology such as intraoperative hormone measurements and intraoperative frozen section evaluations to assure that the patient is indeed cured of the disease before the surgery is ended. We also use intraoperative laryngeal nerve monitoring to be able to localize and preserve the vocal cord nerves and minimize risk of vocal cord paralysis during the surgery.
Surgery is the most common treatment for hyperparathyroidism, and has a 95 percent success rate in curing the disease when performed by an experienced doctor. Surgical removal of one or more abnormally enlarged parathyroid glands is called parathyroidectomy. Not all individuals with hypercalcemia or hyperparathyroidism require parathyroid surgery. In fact, approximately 50% of patients with known hyperparathyroidism do not meet the criteria for becoming candidates for surgery.
These are patients who have been diagnosed to have mildly elevated calcium with mild elevations in parathyroid hormone (PTH) by blood testing, but do not have any overt manifestation of hyperparathyroidism. These patients can be followed regularly and closely by their primary care physician or endocrinologist for evidence of progression of the disease to more severe levels. They need to have their blood calcium levels and bone density measured periodically and should be examined by their doctor to detect early signs of the disease. There are also medications available to treat hyperparathyroidism. However, over 50% of patients are candidates for surgery, and fortunately 95% of them can be cured by one surgical procedure. The only definitive cure is achieved through surgery. During the operation, the patient is given either general or local anesthesia. Your surgeon will make a small incision in the neck just under the Adam’s apple and remove the abnormal gland(s) through that incision. The particular type of the disease, and whether or not one or more glands are affected, will determine how many glands need to be removed.
Some healthy parathyroid tissue needs to be left in place to prevent hypoparathyroidism (decreased parathyroid hormone level). To identify the abnormal gland(s) prior to surgery, a high resolution ultrasound and a radionuclide parathyroid scans are quite helpful in most cases and give the necessary anatomic information that the surgeon needs. With accurate localization of the abnormal gland(s), a surgeon familiar with the minimally invasive parathyroid surgery can perform that surgical technique with distinct advantages to the patient.
Minimally Invasive Parathyroid Surgery
Minimally invasive parathyroid surgery has become increasingly popular in the hands of experienced parathyroid surgeons.
In this type of surgical approach, unlike the conventional surgical approach, the surgical incision is about 2.5-3.0 centimeters long, as opposed to 5-6 centimeters in length.
The incision is smaller and heals better, leaving a smaller and almost invisible scar.
In addition, in minimally invasive parathyroid surgery (parathyroidectomy), the tissues are dissected to a lesser extent with fewer traumas to the surrounding tissues. In this technique, depending on the expertise and preference of the surgeon, either fiberoptic endoscopes and video cameras are used (“minimally invasive Video Assisted Parathyroid Surgery”), or special probes capable of detecting radionuclide levels (injected in the patient’s blood circulation before the surgery starts) are utilized to find and locate the abnormal gland(s).
The rate of cure and complications are about the same as conventional four gland bilateral exploration, but the length of surgery is generally shorter, thus exposing the patient to shorter anesthesia time. In selected cases, the patient can go home the day of surgery. Others may be kept at the hospital for overnight observation, to be discharged home the day after surgery.
Parathyroid Surgery FAQs
WHAT IS THE FUNCTION OF PARATHYROID GLANDS?
The purpose of parathyroid glands is to produce parathyroid hormone (PTH), which regulates and maintains calcium levels in the blood. When the blood calcium level falls too low, the parathyroid glands secrete just enough PTH to restore the calcium level to normal.
The calcium reserves are stored in our bones and in response to PTH, calcium is released from the bones into the blood circulation. In addition, PTH promotes absorption of calcium in our intestines from dietary sources (dairy products etc.).
WHY IS CALCIUM IN MY BODY SO IMPORTANT?
Calcium is an essential element in the body.
It plays a vital role in the development of bone and tooth and helps maintains their strength. Calcium also plays a very important role in muscle contraction and nerve transmission, as well as in many other vital biochemical interactions in our bodies.
WHAT IS HYPERPARATHYROIDISM AND WHY DOES IT HAPPEN?
Overproduction of the parathyroid hormone by abnormally enlarged parathyroid glands, due to any cause, is called hyperparathyroidism. The cause is usually unknown but is thought to be genetically linked in approximately 5% of cases. It is two times more prevalent in women than in men. The incidence in both men and women increases with age.
The signs and symptoms are often subtle and include kidney stones, premature osteoporosis detected by bone densitometry, generalized and unexplained weakness and fatigue. In addition, depression and impaired thinking and memory are attributed to hyperparathyroidism. Nausea, constipation, loss of appetite and increased thirst and urination could be the presenting symptoms. High blood pressure and peptic ulcer disease (stomach and duodenal ulcers) are also closely associated conditions.
HOW IS HYPERPARATHYROIDISM DIAGNOSED?
A simple blood test can be done to see if the calcium and PTH levels in the blood circulation are too high.
An ultrasound of the parathyroid glands and a radionuclide test (Sestamibi scan) will be needed for thorough evaluation and localization of the abnormal glands. Because high PTH levels can cause bones to weaken from excessive calcium loss, a measurement of bone density may help assess bone loss and risk of fractures.
Ultrasound or X-ray of abdomen may reveal kidney stones, and a 24-hour urine test may show excessive excretion of calcium in the urine and as such, an elevated risk of future kidney stone formation.
WHO IS IN CHARGE OF TREATING MY HYPERPARATHYROIDISM?
Close communication and coordination of care ought to take place between your primary care physician, your endocrinologist and Dr. Babajanian to manage your care appropriately. You may have such a mild case of hyperparathyroidism that you just need to be watched carefully and periodically, with no immediate need for surgery.
If you are deemed to be an appropriate surgical candidate, you will be referred to Dr. Babajanian to undergo surgery for removal of the abnormal parathyroid gland, an operation called parathyroidectomy.
Dr. Babajanian places an emphasis on active participation of all your designated physicians and yourself in the decision making process.
WHAT IS MY EXPECTED LEVEL OF ACTIVITY AND DIET AFTER PARATHYROID SURGERY?
Parathyroid surgery is by and large a safe and effective surgery.
Recovery after parathyroid surgery is generally easy and simple. You will be discharged home either the day of surgery or the following day, based on your general condition and health. You will be able to talk, eat, walk and breathe comfortably, immediately after surgery. You should avoid strenuous activities and heavy exercise for one week after surgery. Your diet will be unrestricted. We encourage that you maintain adequate amount of calcium in your daily diet in order to replenish the loss of calcium that occurred while you had hyperparathyroidism before surgery. In some cases, we will place you on calcium supplements if needed, but otherwise no new medications are needed after surgery. You may return to all basic daily activities, including driving, within 1-2 days of surgery.
HOW LONG IS THE LENGTH OF SURGERY?
Parathyroid surgery varies in length and extent. It may take anywhere from 30 minutes to several hours depending on the ease of localization of the tumor and the number of the abnormal glands to be removed.
Minimally invasive parathyroidectomy may take 30 minutes to an hour to complete in those patients who have well localized tumors.
Revision parathyroidectomies, on the other hand may need much longer time to finish. During the surgery we will immediately measure your post treatment parathyroid hormone level to ascertain that you are indeed cured.