eMedicine Specialties > Radiology > Head/Neck

Parathyroid Adenoma

Author: Glenda Romero-Urquhart, MD, Staff Physician, Department of Radiology, Harbor Medical Center, University of California at Los Angeles
Coauthor(s): Fred S Mishkin, MD, Professor of Radiology in Residence, University of California at Los Angeles School of Medicine; Director, Division of Nuclear Medicine, UCLA-Harbor Medical Center; Panukorn Vasinrapee, MD, Assistant Clinical Professor of Radiology, University of California at Los Angeles School of Medicine, Physician Specialist in Nuclear Medicine, Department of Radiology, UCLA-Harbor Medical Center
Contributor Information and Disclosures

Updated: Apr 13, 2007

Introduction

Background

Primary hyperparathyroidism (HPT) is a condition characterized by an inappropriate excess of parathyroid hormone (PTH) secretion. The elevated PTH levels result in hypercalcemia and hypophosphatemia. Primary HPT is caused by parathyroid adenoma in 80-85% of patients, by multiple parathyroid adenomas in 2-3%, by parathyroid hyperplasia in 10-15%, and by parathyroid carcinoma in 2-3% of patients.1

For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education article Thyroid Problems.

Pathophysiology

The primary function of the parathyroid glands is to help regulate calcium homeostasis by producing PTH in response to hypocalcemia. PTH stimulates bone resorption, which in turn releases calcium. In primary HPT, excess PTH release results in hypercalcemia. Hypercalcemia is believed to be responsible for the clinical manifestations of the disease.

Frequency

United States

Primary HPT affects approximately 1 person per 500-1000 population.2

Mortality/Morbidity

  • Most patients with primary HPT present with asymptomatic hypercalcemia.
  • Common clinical presentations are believed to result from bone resorption and high serum concentrations of calcium. Common findings include nephrolithiasis, bone pain, arthralgias, muscular aches, peptic ulcer disease, pancreatitis, fatigue, depression, anxiety, and other mental disturbances.
  • The symptoms can be remembered with the following expression: stones, bones, groans, and psychic overtones.

Sex

  • Primary HPT is 2-4 times more common in women than in men.
  • Clark and Duh estimated that 1 woman in 500 and 1 man in 2000 older than 40 years are affected by this entity.3

Age

  • Primary HPT most commonly affects middle-aged adults; it is rare in children.
  • Reportedly, 1 woman in 500 and 1 man in 200 who are older than 40 years have primary HPT.3

Anatomy

Most individuals (83%) have 4 parathyroid glands: 2 superior glands and 2 inferior glands. Akerstrom et al report that approximately 13% of individuals have more than 4 glands, and 3% have only 3 glands.

Normal glands are encapsulated, soft, ovoid, yellowish-white organs surrounded by fat. According to Higgins, each gland measures approximately 5 X 3 X 1 mm and weighs approximately 40 mg. Glands receive most of their blood supply from branches of the paired inferior thyroid arteries. The paired superior thyroid arteries, thyroidea ima artery, and branches of the laryngeal and tracheoesophageal arteries may also supply the parathyroid glands.

Embryologically, the superior parathyroid glands are derived from the fourth pharyngeal pouch, and the inferior parathyroid glands are derived from the third pharyngeal pouch. The inferior thyroid glands develop in conjunction with the thymus and usually descend into the lower neck with the thymus. Most commonly, the superior parathyroid glands come to lie posterior to the upper-mid pole of the thyroid glands, and the inferior parathyroid glands usually lie on the anterolateral or posterolateral surface of the lower thyroid pole.

Akerstrom et al reported ectopic parathyroid glands in 20% of patients.4 The inferior parathyroid glands tend to be more variable and ectopic. They can be found anywhere along the thymus line of descent.

Notable ectopic locations for the inferior parathyroid glands include the following: (1) near the hyoid bone, (2) within the carotid sheath, (3) superior to the thyroid gland, (4) intrathyroidal, (5) intrathymic, and (6) mediastinal.

Common ectopic locations for the superior parathyroid glands include the following: (1) tracheoesophageal groove, (2) retroesophageal space, (3) carotid sheath, and (4) posterosuperior mediastinum.

Presentation

Common clinical presentations include nephrolithiasis, bone pain, arthralgias, muscular aches, peptic ulcer disease, pancreatitis, fatigue, depression, anxiety, and other mental disturbances.

Preferred Examination

Indications for imaging

Imaging studies should be performed only after the diagnosis of primary HPT is established on the basis of biochemical findings. In patients with primary HPT who have not undergone previous neck surgery, preoperative localization imaging is controversial. Experienced surgeons have a 90-95% cure rate in patients with primary HPT who undergo neck exploration for the first time, as Salti reported.5

Shaha et al describe the following patients in whom preoperative imaging studies are warranted6 :



  • Asymptomatic patients with mild hypercalcemia
  • Patients in hypercalcemic crisis in whom urgent diagnosis is needed
  • Patients with associated malignancies
  • Obese patients with short necks
  • Patients with cervical spinal problems in whom neck extension may be difficult
  • Patients with associated palpable thyroid abnormalities
  • High-risk patients in whom operative time is crucial or in whom local anesthesia must be used

Levin and Clark reported that the most common reasons for missed parathyroid glands during surgery are the presence of multiple abnormal glands, ectopic parathyroid glands, and surgical inexperience.7 These are additional reasons for the use of preoperative localization studies.

In general, preoperative localization studies should be performed in patients who have undergone unsuccessful neck exploration, in contrast to patients who have not. Surgical success rates with repeat exploration are significantly lower than those with primary surgery.

Available imaging studies

Several noninvasive and invasive studies are available. Noninvasive studies include scintigraphy, ultrasonography (US), CT, and MRI. Perform the noninvasive studies first.

If the findings of the noninvasive studies are equivocal or nondiagnostic, perform the invasive procedures, such as parathyroid selective arteriography and/or selective parathyroid venous sampling. Currently, the preferred examination is dual-phase scintigraphy with the radiopharmaceuticals technetium Tc 99m sestamibi or technetium Tc 99m tetrofosmin.

Limitations of Techniques

One limitation common to all noninvasive and invasive studies is their low sensitivity in detecting small parathyroid adenomas. Limitations of each study are discussed in the following relevant sections.

Differential Diagnoses

Thyroid Nodules

Other Problems to Be Considered

Hyperplastic parathyroid gland
Parathyroid carcinoma
Thyroid nodules
Enlarged lymph nodes
Sarcoid granulomas
Neurofibromas
Other neck masses

More on Parathyroid Adenoma

Overview: Parathyroid Adenoma
Imaging: Parathyroid Adenoma
Follow-up: Parathyroid Adenoma
Multimedia: Parathyroid Adenoma
References
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References

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Further Reading

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Keywords

HPT, primary hyperparathyroidism, excess parathyroid hormone, PTH, hypercalcemia, hypophosphatemia

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Contributor Information and Disclosures

Author

Glenda Romero-Urquhart, MD, Staff Physician, Department of Radiology, Harbor Medical Center, University of California at Los Angeles
Glenda Romero-Urquhart, MD is a member of the following medical societies: American College of Radiology
Disclosure: Nothing to disclose.

Coauthor(s)

Fred S Mishkin, MD, Professor of Radiology in Residence, University of California at Los Angeles School of Medicine; Director, Division of Nuclear Medicine, UCLA-Harbor Medical Center
Fred S Mishkin, MD is a member of the following medical societies: American College of Angiology, American College of Radiology, American Heart Association, American Medical Association, California Medical Association, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

Panukorn Vasinrapee, MD, Assistant Clinical Professor of Radiology, University of California at Los Angeles School of Medicine, Physician Specialist in Nuclear Medicine, Department of Radiology, UCLA-Harbor Medical Center
Panukorn Vasinrapee, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

Medical Editor

Hussein M Abdel-Dayem, MD, Chief, Nuclear Medicine Service, Department of Radiology, Professor of Radiology, St Vincent's Catholic Medical Centers of New York
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

C Douglas Phillips, MD, Professor, Departments of Radiology, Neurosurgery, and Otolaryngology, University of Virginia Health Sciences Center
C Douglas Phillips, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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