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BackTable / ENT / Article
Parathyroid Disease Diagnosis, Symptoms, & Surgical Criteria
Melissa Malena • Jul 30, 2023 • 117 hits
Parathyroid disease is often difficult to diagnose with patients coming in with vague symptoms of fatigue and delocalized pain. A parathyroid disease diagnosis requires blood tests with elevated serum calcium and parathyroid hormone. There are three stages of parathyroid disease, primary hyperparathyroidism, secondary hyperparathyroidism and tertiary hyperparathyroidism. According to expert head and neck surgical oncologist, Dr. David Goldberg, primary hyperparathyroidism can be treated surgically with a parathyroidectomy, if bloodwork and imaging studies conclude surgery as a viable option. Operational success is determined by a post excision rapid parathyroid hormone test, expecting levels to drastically lower once the hyperactive gland is removed. Post operative care focuses on calcium intake to avoid the most common complication, hungry bone syndrome.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Primary hyperparathyroidism diagnosis primarily relies on lab tests indicating elevated serum calcium and parathyroid hormone levels. Additional tests such as 24-hour urine calcium and vitamin D status can further refine diagnosis and treatment plans.
• Surgery for primary hyperparathyroidism is considered for patients with diagnostic blood work, symptomatic patients, and localizing studies, regardless of the symptoms' vague or non-specific nature.
• Baseline lab tests are taken at the beginning of the surgery and again 15 minutes after excision, often leading to a waiting period despite the so-called "Rapid PTH" testing approach.
• Postoperative care after parathyroid surgery often involves a calcium taper to prevent hungry bone syndrome, a condition where the body rapidly absorbs calcium into the bones, resulting in low serum calcium levels (hypocalcemia).
Table of Contents
(1) Parathyroid Disease Symptoms & Diagnosis
(2) Surgical Criteria for Parathyroidectomy
(3) Defining Parathyroidectomy Procedural Success
(4) Parathyroidectomy Postoperative Care
Parathyroid Disease Symptoms & Diagnosis
Symptoms of parathyroid disease may be non-specific, including fatigue, mental fog, bone or abdominal pain, and poor sleep habits, which are frequently overlooked in perimenopausal women. Dr. Goldenberg uses lab tests in diagnosing primary hyperparathyroidism, where high serum calcium and elevated parathyroid hormone levels are indicative. An additional consideration is the patient's vitamin D status as those deficient in this nutrient often exhibit more severe symptoms. Hyperthyroidism is measured in stages, with secondary and tertiary hyperparathyroidism usually being managed medically unless the patient is refractory.
[Dr. Ashley Agan]
We're talking about the management of parathyroid disease. Just starting out, what are the symptoms that these patients are coming in with? What does your history look like? What symptoms are you expecting to see?
[Dr. David Goldenberg]
All of us in medical school were taught moans, bones, stones, and groans, where people came in with profound symptoms. Fortunately, we don't see those kinds of symptoms anymore. About 20 or 30% will come in with a history of kidney stones, but many of the patients have non-specific symptoms such as fatigue, mental fog, bone or abdominal pain, and poor sleep habits. Since primary hyperparathyroidism often occurs in perimenopausal women, oftentimes, those symptoms are dismissed and the patients find them very, very vexing. The good news is that parathyroid surgery actually cures many of these symptoms, if not all of them, and very quickly indeed.
[Dr. Ashley Agan]
Most of these patients when they're making their way to you, have they already been diagnosed from labs? Their primary care, somebody has picked it up and then they said, okay, we need to send you on to be further evaluated?
[Dr. David Goldenberg]
In my practice, the vast majority are sent to me either by primary care physician or an endocrinologist. Labs are actually the core of the diagnosis to have a diagnosis of primary hyperparathyroidism. Ideally, one will come in with an elevated serum calcium and elevated parathyroid hormone, and that's the core. There are other labs which are helpful, such as 24-hour urine calcium, which precludes the diagnosis of FHH and that's important. Another one is vitamin D is also important because people who are vitamin D deficient and have primary hyperparathyroidism typically are sicker. Their numbers are higher, and it should be addressed prior to surgery.
[Dr. Ashley Agan]
Then just to stop you, FHH being familial hypercalcemia?
[Dr. David Goldenberg]
Hypercalcemia, yes. I'm sorry.
[Dr. Ashley Agan]
It's okay. Just for listeners who may not know. Most people, you think, like primary care, are doing annual screening and maybe checking BMP and maybe vitamin D, and then if the calcium is high, then reflexively getting a PTH level. Is that typically how it works?
[Dr. David Goldenberg]
Unfortunately, oftentimes, a patient will come in with a long history of hypercalcemia that was being "watched." If things are done correctly, then the patient has elevated calcium and there are other reasons for elevated calcium. Those absolutely have to be ruled out. As a matter of fact, some of them are very serious, such as malignancy. Malignancy and primary hyperparathyroidism together are about 90%, 95% of all hypercalcemia. Once more serious things are ruled out and once certain drugs such as thiazides and lithium are ruled out as a cause, then yes, parathyroid hormone is done and the patients are sent on for definitive care.
[Dr. Dipan Desai]
Dr. Goldenberg, how do you approach a patient who's maybe borderline, they've maybe had an elevated calcium some time ago and their labs vary between the normal range and mildly elevated?
[Dr. David Goldenberg]
This is where some clinical decision-making comes in. It depends on their symptoms, it depends on their parathyroid hormone. There are certainly patients who come in thinking that they have hyperparathyroidism because they read on the internet the symptoms and their calcium and their parathyroid hormone are both normal or within the normal range. That's a conversation that's sometimes difficult. If a patient is, sometimes it's high, sometimes it's low, I may get them an imaging study to see if there is something there. There have been patients where I said, this has not declared itself quite yet. Let's get you another calcium in six months. It really does depend.
[Dr. Dipan Desai]
Obviously, we've been focusing mostly on primary hyperparathyroidism so far, and we won't delve fully, for the interest of time, into secondary or tertiary hyperparathyroidism, but how do you approach those patients and is there anything different in terms of your history or your physical exam?
[Dr. David Goldenberg]
Patients who have secondary or tertiary hyperparathyroidism, they come to us from nephrology, they're very sick, typically. Their calcium does not always have to be elevated, parathyroid hormone can be very elevated. Secondary hyperparathyroidism if possible should be treated medically, it's only the patients who are refractory who come to surgery. Those patients will obviously get a far more extensive dissection and exploration.
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Surgical Criteria for Parathyroidectomy
Surgical intervention is the chosen management technique for primary hyperparathyroidism. Criteria for parathyroidectomy include symptomatic patients with diagnostic blood work and localizing studies. Most patients suffer from a single parathyroid adenoma, however, a small proportion (15-25%) have more than one abnormal gland. The presence of a double adenoma or four-gland hyperplasia (overactivity of all four glands) necessitates addressing each gland. Hyperplasia, while less common, ‘tricks’ the body into leaching calcium from bones, leading to osteopenia and ultimately osteoporosis if untreated. The cause of this phenomenon remains elusive, but it generally appears in the same demographic as primary hyperparathyroidism—mainly women in their perimenopausal years.
[Dr. Dipan Desai]
For your standard primary hyperparathyroidism patient, what are your criteria for parathyroidectomy?
[Dr. David Goldenberg]
There's the old NIH criteria for parathyroidectomy if symptomatic with serum calcium, life-threatening, et cetera, et cetera. Like I said at the beginning, the vast majority of patients who we see do have symptoms, they are just vague or non-specific but they're there and they really do bother the patient. In my mind, if the patient has a localizing study and if they have blood work which is indicative, then they're going to surgery. I do have very few patients who are actually symptom-free and they obviously have an adenoma. They too probably, I would take them to surgery as well.
[Dr. Ashley Agan]
Just to back up, so most patients who have primary hyperparathyroidism have a single parathyroid adenoma that is causing that, would you say?
[Dr. David Goldenberg]
The vast majority. The vast majority of patients have a single adenoma, and then there are about 15 to 25% who will have more than one abnormal gland. There is such a thing as a double adenoma. More often they will have four-gland hyperplasia, in which case all four of the glands need to be addressed. Rarely, and I say incredibly rare, there's 1%, there's a parathyroid carcinoma.
[Dr. Ashley Agan]
Interesting. With the four-gland hyperplasia, so with that, there's not an adenoma. All four glands are just hyper-functioning, is that the right way to think about it?
[Dr. David Goldenberg]
Correct. Yes. That's exactly what it is. All four glands are hyper-functioning and they're tricking the body into thinking that it needs more calcium in the blood and it leeches it obviously from the bone. Patients will develop osteopenia and ultimately osteoporosis if they don't get it taken care of.
[Dr. Ashley Agan]
With four-gland hyperplasia, do we know what the underlying issue is? Why does that happen? Is that perimenopausal as well? Is that patient demographic different?
[Dr. David Goldenberg]
Not really. It should be the same mechanism. It just affects all four glands. It is obviously a lot less common. To my knowledge, it's the same demographic. It's not that men can't get this, it's just that more often it's a woman's disease and those are the age group.
[Dr. Ashley Agan]
Got you.
Defining Parathyroidectomy Procedural Success
In patients with four-gland hyperplasia and secondary parathyroidism, typically three to three and a half glands are removed, with parathyroid hormone levels monitored to ensure effectiveness. According to Dr. Goldenberg laboratory tests are a critical part of this process, with the primary measure being the hormone level 15 minutes after the removal of the glands. Despite the name "Rapid PTH," this test often involves a waiting period before results are available. These lab tests, which form the baseline for further treatment decisions, are taken at the start of the surgery and 15 minutes post excision. If the post excision lab test does not show the correct reduction in parathyroid hormone, the problematic gland is still active and the surgeon must decide the best course of further treatment.
[Dr. Dipan Desai]
If you are treating a four-lane hyperplasia or a secondary parathyroidism case, are you typically taking three or three and a half or is that not always a fixed rule?
[Dr. David Goldenberg]
Yes, between three and three and a half and I do follow the parathyroid hormone. There have been times that I've left three and it's done our job. There have been times where even that doesn't do it.
[Dr. Dipan Desai]
I see. Can you talk through when you draw those labs, you said, I know up to 15 minutes out, but what are the time points?
[Dr. David Goldenberg]
I draw labs 15 minutes after removal of whatever I'm looking after. I've had cases earlier in my career where 10 minutes just didn't cut it and so I just decided on 15, there are people who do 20 as well. I don't know about how it is at Hopkins now with Rapid PTH, in my institution it isn't as rapid as its name. There's a lot of waiting around, singing campfire songs while we wait for the parathyroid hormone to come back.
[Dr. Dipan Desai]
Yes, it's the longest 45 minutes of the day sometimes. You're drawing just in 15 minutes or you're getting one at 0, 5, 10 and 15 minutes?
[Dr. David Goldenberg]
No, I'm sorry, I should have been clearer. Yes, so the anesthesiologist draws it at the beginning of surgery. That's their baseline then 15 minutes afterwards. I have them draw when surgery starts, they take it from the foot, the patients wake up and ask why they have a needle hole in their foot. That's where we do it out of 15 minutes after excision of whatever it is, I'm excising.
Parathyroidectomy Postoperative Care
Dr. Goldenberg lays out his protocol for the postoperative care of patients who undergo a parathyroidectomy. Calcium supplementation and monitoring after surgery is vital, as this helps prevent potential complications such as hungry bone syndrome. Hungry bone syndrome is a condition characterized by rapid calcium absorption by the bones, leading to hypocalcemia that can occur after parathyroidectomy. The results of parathyroid surgery are often gratifying, with patients often reporting significant improvement in parathyroid disease symptoms within a week of surgery.
[Dr. Dipan Desai]
Then once you've completed your surgery, and you've successfully found the parathyroids, and your labs have corrected, postoperatively you mentioned your admitting versus discharge patterns. Do you give them any medication afterward or any calcium taper? Anything special you do in the postoperative period?
[Dr. David Goldenberg]
We do typically give them a small calcium taper. I wish I could tell you that I've been successful in being able to differentiate those who are going to develop hungry bone syndrome or something like that. It happens. We just don't want the patients to go home and start to feel sick. They are given calcium taper. I forgot to mention. I think where I have mentioned in the beginning, hopefully, their vitamin D was optimized before surgery, we try to do that. They go home, they're usually happy and we do see their calcium pretty soon afterwards. Most of them are just great. They're very happy, they feel great.
It's a very gratifying surgery as a surgeon to be perfectly honest. The array of symptoms abates very quickly. As a matter of fact, we published a study in laryngoscopes, I believe in '18, or '19, where we looked at cognitive symptoms, depression scores before and after surgery. We found that within a week of surgery, the patients were like new people. Their scores came up, their depression was down. Right now we're actually doing a study looking at using actigraphy to look at patients' sleep habits before and after surgery, because most of these patients do very, very well, and they feel like new people very soon after surgery.
[Dr. Dipan Desai]
Yes. I agree with you completely. It's a super gratifying surgery, and oftentimes, just as you mentioned earlier, in the podcast, they've had symptoms that have been either misdiagnosed or neglected as just part of aging for a long time and, to do something where they pretty much instantly feel better is pretty awesome.
[Dr. David Goldenberg]
If I could give a title to parathyroid surgery, the title would be, ''You've given me my old wife back'' because I've heard so many husbands say that after parathyroid surgery.
[Dr. Ashley Agan]
Wow.
[Dr. Dipan Desai]
You briefly mentioned hungry bone syndrome. Can you talk a little bit about what that is and who is prone to getting it?
[Dr. David Goldenberg]
Sometimes what happens is, the serum calcium decreases relatively quickly because of re-calcification of the bones. Remember, the bones got leached of their calcium, and now they want it back. It's called hungry bone syndrome. It typically happens within the first days or weeks after surgery. It's typically a sequela of more symptomatic hypercalcemia. People feel yucky. They have muscle cramps, and they have a clinical picture of tetany, just like they would for any other hypocalcemia. That's one of the reasons that we support patients with calcium orally. If this happens, then they come in, and they usually get intravenous calcium infusions.
It can be relatively dangerous if it's not treated at all because it is a form of hypocalcemia. It's not common, but it's something that we do see, and the patients typically need to be made aware of the signs of hypocalcemia, so that they could recognize it once they go home. That's why it's important to educate your patients. In my practice, we're the only academic show in town to have patients come from far and wide across the Commonwealth of Pennsylvania, and certainly, you don't want someone going who lives four hours away, they have the signs and symptoms and they don't really know what's going on.
[Dr. Ashley Agan]
Postoperatively, are you checking calcium levels routinely?
[Dr. David Goldenberg]
I think they get a calcium check before discharge typically, and they go home on calcium. I wish I could tell you exactly what the protocol is. I don't know.
[Dr. Ashley Agan]
Do you just use TUMS like calcium carbonate?
[Dr. David Goldenberg]
Yes, typically, we do use calcium carbonate.
[Dr. Ashley Agan]
Cool.
[Dr. Dipan Desai]
Obviously, a lot has been made in regard to innovations around parathyroid surgery with autofluorescence of parathyroid glands during thyroid surgery. Can you speak to if that's useful at all during parathyroid surgery, you're trying to find a hard parathyroid gland?
[Dr. David Goldenberg]
I can't speak from experience because I don't know, I don't use it. In theory, the autofluorescence of parathyroids that they fluoresce has been used, so you don't accidentally avulse. You can see them so you don't avulse them during thyroid surgery. People have said, ''Okay. Can we use that same technology to find a hard to find parathyroid?' Again, I haven't used it, but I've been around long enough to know or to remember when they did the same thing with methylene blue. There have been multiple attempts to try and dye the parathyroid in order to find it. I guess anything that helps is wonderful. Typically, the surgical principles are enough to find the offending parathyroid in my mind, but again, I've not done it, so I can't speak to it.
[Dr. Dipan Desai]
No. Sure. Thanks for letting me know.
Podcast Contributors
Dr. David Goldenberg
Dr. David Goldenberg is a professor and the chair of the department of otolaryngology - head and neck surgery at Penn State in Hershey, Pennsylvania.
Dr. Dipan Desai
Dr. Dipan Desai is a practicing otolaryngologst and head and neck surgeon with ENT Associates in St. Petersburg, Florida.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, January 17). Ep. 85 – Surgical Management of Parathyroid Disease [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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