Parathyroid Gland Disorders and Surgery

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What is the Parathyroid Gland?

The parathyroid glands are four small structures situated just behind the thyroid gland. They secrete parathyroid hormones essential for regulating blood calcium levels. This, in turn, ensures the proper functioning of multiple organ systems and is responsible for regulating calcium in the body.

parathyroid glands
The parathyroid glands are pea-sized glands on the back of the thyroid.

What are Parathyroid Gland Disorders?

Parathyroid gland disorders occur in Singapore when the levels of parathyroid hormones become too high or too low, resulting in an imbalance of calcium in the body. There are two main types of parathyroid disorders, these are:

  • Primary hyperparathyroidism: hyperparathyroidism occurs when one or more parathyroid glands produce too much hormone. The most common cause of hyperparathyroidism is parathyroid adenoma, a noncancerous growth on one of the parathyroid glands. In approximately 85% of hyperparathyroidism cases, a single adenoma is responsible. The other 10-15% are typically linked to abnormalities in two or more glands. The excess parathyroid hormone leads to elevated blood calcium levels, resulting in symptoms such as kidney stones, frequent urination, fatigue, joint or bone pain, and depression.
  • Hypoparathyroidism: when one or more of these glands underproduce parathyroid hormone, it leads to a condition known as hypoparathyroidism. This leads to high phosphorus and low calcium levels in the blood. Symptoms include heart arrhythmias, brain fog, muscle cramps, weak and brittle nails, cataracts, and abdominal pain.
parathyroid disorders
An imbalance of parathyroid hormones results in abnormal calcium levels in the blood.

What are the treatment options for Parathyroid Gland Disorders in Singapore?

Parathyroid gland disorders can be managed and treated using a variety of procedures. The four commonly used approaches for diagnosing, managing, and treating common parathyroid gland disorders include:

  • Minimally invasive video-assisted parathyroidectomy (MIVAP)
  • Bilateral neck exploration for primary hyperparathyroidism
  • Focuses parathyroid surgery for image localised tumours
  • Total parathyroidectomy and deltoid autotransplant for renal failure/secondary hyperparathyroidism

Minimally invasive video-assisted parathyroidectomy (MIVAP)

Primary hyperparathyroidism is commonly treated with surgery. Once a parathyroid adenoma has been identified as the cause of hyperparathyroidism, a minimally invasive parathyroidectomy – the treatment will be performed. It is achieved through a small neck incision, approximately 2-2.5 cm long, and uses video imaging to ensure accurate removal of abnormal parathyroid glands.

parathyroid removal
Parathyroidectomy involves the removal of abnormal parathyroid glands.

What are the benefits of MIVAP?

One of the main benefits of successfully removing the abnormal parathyroid gland is curing the patient of the disease and reversing many of the preceding harmful effects of excess parathyroid hormone.

  • Good surgical technique: MIVAP removes abnormal parathyroid glands while minimising the size of incisions and optimising video-assisted technology. This also improves cosmetic appearance due to smaller and more cosmetically appealing scars.
  • Reduced surgical trauma: MIVAP involves smaller incisions compared to traditional open surgery, resulting in less tissue disruption and faster healing.
  • Enhanced visualisation: video-assisted technology gives the surgeon a magnified and detailed view of the surgical area, aiding in effective gland removal and avoiding damage to critical structures such as the voice nerve and blood vessels.
  • Shorter recovery time: patients typically experience less postoperative pain and discomfort, and many do not need any painkillers after a few days. Most patients can return home on the day of surgery or after an overnight stay at the hospital. 
  • High success rate: MIVAP has a high success rate in treating parathyroid adenomas/tumours.

Bilateral neck exploration in primary hyperparathyroidism 

This is a surgical procedure performed in selected cases of primary hyperparathyroidism when imaging studies have failed to identify the abnormal gland. This can occur in 10-15% of patients due to generalised hyperplasia (swelling) of all four glands or an ectopic location of the gland in the neck. 

The radiological imaging procedures used to help localise the parathyroid adenoma are not 100% accurate and occasionally are negative. In such cases, the parathyroid surgeon must use his skills and experience to explore the neck on both sides to locate and remove the abnormal gland and cure the patient.

Imaging studies may not be able to identify the cause of hyperparathyroidism in 10-15% of cases.

Tertiary/renal hyperparathyroidism  

The majority of patients on dialysis for renal failure will eventually develop hyperparathyroidism secondary to their underlying disease after many years. When medications stop working, a total parathyroidectomy with autotransplant of a tiny fragment of parathyroid tissue is the only option for definitive management of their symptoms and pathology. A bilateral neck exploration is done under general anaesthesia to excise all parathyroid tissue from the neck and implant a tiny fragment in the arm. 
At ACE Specialist Surgery and Endoscopy, we have developed proven protocols for safe peri-operative management of these high-risk patients with a multidisciplinary team of renal physicians, endocrinologists, and ICU anaesthesiologists.

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Reyaz Moiz

Dr Reyaz Singaporewalla
Senior Consultant Endocrine and General Surgeon

MBBS (Bom), MS (Surg), DNB (Surg), FRCS (Edin), MMed (Singapore), FRCSEd.