Parathyroid Diseases and Management

1. Dr. Ritesh Dhanbhar

2. ANATOMY
 Endocrine glands situated behind thyroid gland.
 Four in number.
 Weight: (40-50)gms
 Secrete: Parathormone.
 Superior glands:
Develop from 4th pharyngeal pouch.
Behind RLN.

3. ANATOMY
 Inferior glands:
Develop from 3rd pharyngeal pouch.
Front of RLN.
Variable positions:
1.Tracheo-oesophageal groove.
2.Behind oesophagus.
3.Carotid sheath.
 Blood supply: Inferior thyroid artery (End artery).

4. PARATHORMONE
 84 amino acids.
 Secretion not dependent on pituitary gland.
 Half life: 4 minutes.
 Functions:
1.Converts vitamin D into 1,25-dihydrocholecalciferol in
kidney.
2.Absorption of calcium from gut.
3.Mobilises calcium from bone.
4.Reabsorption from renal tubules.

5. CALCIUM
 Normal value: (8.5-10.2)mg/dl.
 Commonest protein part of bound calcium is Albumin
(80%).
 Level controlled by:
PTH
Calcitonin
Vitamin D- Acts on bone, kidney and GIT.

6. CALCIUM
 Functions:
1.Blood coagulation.
2.Neuromuscular activity.
3.Cellular activity.
4.Bone integrity.

7. HYPERPARATHYROIDISM (HPT)
 Types:
1.Primary.
2.Secondary.
3.Tertiary.

8. PRIMARY HPT
 3rd most common endocrine disease.
 Causes hypercalcaemia.
 Etiology:
Parathyroid adenoma.
Familial/ genetic causes.
MEN I syndrome.
Therapeutic ionizing radiation.
Lithium: no bone or renal problems.

9. CLINICAL FEATURES
 Clinical vignette: “Bones, stones, abdominal organs
and psychiatric moans”.
 Middle aged women (3:1).
 Incidence: 1: 1000.
 Asymptomatic >50% cases.

10. CLINICAL FEATURES
 Bones:
Raised PTH
Increased osteoclastic activity
Extensive decalcification of bone
Bone pain, subperiosteal erosions.
Osteitis fibrosa cystica: Single/ multiple cysts/
pseudotumours in the jaw, skull or phalanges.
Osteopenia, osteoporosis and pathalogical fractures.

11. CLINICAL FEATURES
 Stones:
Renal stones in 25% patients.
Recurrent stones.
Calcium phosphate and oxalate type.
Metastatic calcification, nephrocalcinosis, renal
failure.
Calcification in renal vessels: renal hypertension.

12. CLINICAL FEATURES
 Abdominal organs:
Stimulates gastrin release: peptic ulceration.
Precipitate acute pancreatitis.
Increases gall stone disease (Calcium bicarbonate).
 Psychic moans:
Behavioural and neurotic problems: Depression and
anxiety.

13. Acute hyperparathyroidism (Crisis)
 Causes:
Sudden increase in PTH due to rupture of parathyroid
cyst or bleeding in parathyroid tumour.
Severe dehydration precipitates crisis.
Secondaries in bone.

14. Acute hyperparathyroidism (Crisis)
 Clinical Presentation:
1.Abdominal pain.
2.Vomiting.
3.Dehydration.
4.Oliguria.
5.Muscular weakness.
6.Death.
 Serum Calcium:>12mg%.

15. Acute hyperparathyroidism (Crisis)
 Treatment:
Forced diuresis: 3-5 litres of saline with frusemide.
Rehydration: normal saline 300ml/hour.
Steroids: Inhibit effects of vitamin D.
Dose: 400mg/day iv for 5 days.
Bisphosphonate:
Clodranate Sodium, Pamidronate
Inhibits mobilization of calcium from bone.
Dose: 4mg iv followed by 8mg.

16. Investigations
Parameters Primary HPT Secondary HPT
Parathormone High High
Calcium High Normal
Phosphate Decreased Increased
•Increased serum PTH level: specific and diagnostic
>0.5.
•Bone density assessment.
•Vitamin D estimation.
•Increased urinary calcium level >250mg/24 hours.
•Raised alkaline phosphatase level.

17. Investigations
 X-Ray features:
Skull: salt and pepper appearance.
Phalanges: subperiosteal bone resorption.
Jaw: osteitis fibrosa cystica.
Spine: rugger jersey spine.
 USG abdomen.
 Thallium- Technetium scan: hot spots (diagnostic of
parathyroid adenoma).

18. Treatment
 Parathyroidectomy.
 Indications for parathyroidectomy:
1.Severe symptoms.
2.Young age group.
3.Markedly reduced bone density.
4.Serum calcium >11mg%.
5.Urinary calculi.
6.Urinary calcium >400mg/24 hours.

19. Parathyroidectomy
 Preoperative preparation:
 Vocal cords assessed.
 Treatment of high calcium levels preoperatively:
1.Diuresis.
2.Steroids: Prednisolone 20mg TDS for 5 days.
3.Phosphate infusion: 100mmol infusion in 6 hours.
4.Calcitonin subcutaneous injection: 200 units BD for 5 days.
5.Biphosphate-Etiodronate disodium: 7.5mg/kg slow iv
infusion for 3 days.
6.Mithramycin: 25microgm/kg single dose.

20. Parathyroidectomy
 Total parathyroidectomy:
For parathyroid hyperplasia.
All four glands removed.
1/3rd of one gland autotransplanted into forearm
muscle (brachioradialis) or sterniocleidomastoid with
marker stitch.
Transplanted gland sliced in 1mm pieces.
18 pieces embedded.

21. Parathyroidectomy
 Adenoma in gland with normal other glands: removal
of single gland.
 Carcinoma: Parathyroidectomy plus
hemithyroidectomy with post operative radiotherapy.
 All 4 glands diseased: Transcervical thymectomy
added.

22. Parathyroidectomy
 Surgical approaches:
Classical approach.
Minimally invasive parathyroidectomy.
Median sternotomy extension.
Video-assisted parathyroidectomy.
Endoscopic parathyroidectomy.
Remedial parathyroidectomy.
Subtotal parathyroidectomy.
Total parathyroidectomy with parathyroid
autotransplantation.

23. Parathyroidectomy
 Complications:
Haemorrhage, RLN palsy, hypocalcaemia.
Persistent HPT: Serum calcium does not normalise
immediately after surgery.
Recurrent HPT: Serum calcium after surgery becomes
normal but again increases in 6-12 months.

24. Parathyroidectomy
Hypoparathyroid with severe hypocalcaemia: 10
ampoules Calcium gluconate with one liter Normal
saline (continuous infusion at 30ml/hour).
Hungry Bone Syndrome:
In patients with preoperative hyperthyroidism.
Increased bone breakdown in hyperthyroid state.

25. Parathyroidectomy
Patient’s thyroid hormone level drops acutely after
surgery, stimulus to brake down bone is removed.
Bones remove calcium from plasma rapidly.
 Presentation: Hypocalcaemia.
Hypophosphatemia.
Hypomagnesemia
Hyperkalaemia.

26. Parathyroidectomy
Vitamin D supplementation and elemental calcium:
for 6 months.
Calcitriol with 2gm calcium supplement.

27. MEN Syndrome
 Autosomal dominant.
 Types:
Type I (Werner’s syndrome):
Parathyroid hyperplasia/Adenoma.
Pituitary tumour.
Pancreatic tumour.
Chromosome 11

28. MEN Syndrome
 Type II (Sipple syndrome):
 Type II A:
Medullary carcinoma thyroid
Pheochromocytoma
Pararthyroid hyperplasia
Chromosome 10.
 Type II B:
Medullary carcinoma thyroid
Pheochromocytoma
Neuroma.

29. APUDOMAS
 APUD (Amine precursor uptake decarboxylation)
 Derived from endoderm.
 Neuron specific enolase enzyme: specific for cells.
 Synthesize peptides:
Endocrine action
Paracrine action
Neurocrine action
Neuroendocrine action.

30. APUDOMAS
 Present like syndromes:
Insulinoma
Glucagonoma
Gastrinoma
VIPoma
 Entopic type: Secrete hormones normal to tissue, like
insulinoma/ glucagonoma.
 Ectopic type: Produce hormones not normal to tissue
of origin, like gastrinoma/VIPoma.

31. APUDOMAS
 Associated with MEN syndrome (Type I).
 Investigation: Radioimmunoassay
MRI abdomen
CT neck

32. Hypoparathyroidism
 PTH level <10pg/ml.
 Types:
1.Temporary:
More common (2-50)%
Lasts for 2months maximum upto 6 months.
Decrease in calcium.
Increase in phosphorous.

33. Hypoparathyroidism
2.Permanent:
Less common (0.4-13)%
Continues beyond 6 months.
Decrease in calcium.
Increase in phosphorous.
3.Hungry bone syndrome:
Common (5-13)%

34. Hypoparathyroidism
 Causes:
Direct trauma to parathyroid glands.
Devascularization of glands.
Removal of gland during surgery.

35. Hypoparathyroidism
 Clinical features:
Circumoral tingling, numbness and paraesthesia.
Carpopedal spasm, laryngeal stridor.
Respiratory muscle spasm, suffocation.
Convulsion.
Cataract formation.

36. Hypoparathyroidism
 Treatment:
 IV calcium gluconate: 10ml in 10% solution over 10
min.
Symptoms not resolve: Calcium infusion at 1-2
mg/kg/hr.
1-2 gm oral calcium per day.
(Calcium carbonate: 1250mg = 500mg elemental
calcium)
Vitamin D supplementation: 0.25-1 microgm/day.

37. THANK YOU !!!