Parathyroid Glands: An Overview
Guest: Dr. Josh Hornig – Otolaryngology/Head & Neck Surgery, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Josh Hornig, who is Assistant Professor of Ear, Nose, and Throat; Otolaryngology, here at MUSC. Dr. Hornig, I know you do a very specialized kind of surgery for the parathyroid glands. Now, just what are the parathyroids?
Dr. Josh Hornig: The parathyroids are glands that are near the thyroid. Their primary role is to control our calcium levels.
Dr. Linda Austin: And why is that important?
Dr. Josh Hornig: The calcium level is critical for nerve function, muscle function, and a host of other areas of the body.
Dr. Linda Austin: So, if there’s a malfunction, what would some of the first symptoms be?
Dr. Josh Hornig: Often, people will get kidney stones, or gall stones, or have muscle aches or fatigue. And then, often, it’s just picked up on a routine blood test.
Dr. Linda Austin: So, you might go in for your annual physical, for example, and the doctor does a blood level and sees that the calcium is high. And then what happens after that, diagnostically?
Dr. Josh Hornig: Typically, once you have a high calcium level, you, usually, have a corresponding level of your parathyroid hormone; and that is also elevated. And once you have an elevated level of parathyroid hormone, then you start looking for disorders of the parathyroid glands, which can range from all the glands being overly active to just one gland being overly active. There are several diagnostic tests that you can do to make that diagnosis.
Dr. Linda Austin: Now, you say all the glands, how many are there?
Dr. Josh Hornig: There are typically four glands; there can be more, or less, but four is the average, normally.
Dr. Linda Austin: So, if there is overactivity, let’s say all four are overactive, do you have to take out all four, or do you get to leave in just one particularly feisty gland, or what do you do?
Dr. Josh Hornig: That is what is most difficult to deal with; when you have four glands that are enlarged. Typically, you’d remove three and a half, and leave one half of the gland still functioning. In the case of one gland being wrong, they’re the easiest ones to fix. In that case, you’d just remove the one gland that’s causing problems.
Dr. Linda Austin: So, can you, as a surgeon, tell which one is overactive just by looking at the size?
Dr. Josh Hornig: The most effective way of doing this is to do an ultrasound of the neck, and also a sestamibi scan; a specialized scan which actually looks for activity of the parathyroid glands. So, if the sestamibi scan shows one gland in particular being hyperactive, you have a focal area for the surgeon to go after.
Dr. Linda Austin: How do you go after it?
Dr. Josh Hornig: There are several ways to do it. The traditional way was a very large incision on the front part of the neck, and you’d look at all four glands, and remove the one gland that you thought was abnormal. With the more sophisticated testing that we have, and the localizing that we can do, and the ultrasounds that surgeons can do now in their offices, we can now make very small incisions; that go from a four inch incision to almost a half inch incision. And we can use specialized instrumentation underneath the skin to minimize tissue dissection, improve recovery, and decrease pain. This new technology has also changed how we treat patients, from keeping them in hospitals for several days to being able to treat them in a day setting. You can do the operation in about 15 minutes, and they can send the people home the same day.
Dr. Linda Austin: And then how quickly can they get back to work?
Dr. Josh Hornig: Generally, they get back very quickly. I usually like people to wait about a week to two weeks, but some people are back at work within several days.
Dr. Linda Austin: Do you ever take out too much, or let’s say you have to take out all four, how, then, does the calcium become regulated?
Dr. Josh Hornig: That’s a great question. Often, when you have one gland that’s overactive, the three remaining glands won’t produce parathyroid hormone as much as they normally would. When you remove the one gland that’s doing all the work, the other three glands can’t do enough work to achieve adequate parathyroid hormone levels. Sometimes after these surgeries, you’ll have exactly the opposite problem of what you came in with. You calcium level, instead of being high, will now be low. So, to prevent that, we’ll actually give people calcium supplementation right after the surgery to try to prevent that from becoming an issue.
Dr. Linda Austin: Are there situations where someone might have to be on calcium supplementation for the rest of their lives?
Dr. Josh Hornig: There are. That usually arises from more thyroid surgery. If we do have to remove all the parathyroid glands, then, yes, you have to be on specialized calcium pills forever.
Dr. Linda Austin: Now, of course, women routinely are on supplemental calcium anyway.
Dr. Josh Hornig: Yes. It’s often not an additional pill that you have to take. Most women that are a little bit older are already on calcium supplementation for osteoporosis.
Dr. Linda Austin: Now, how about the opposite problem, if calcium levels drop?
Dr. Josh Hornig: That’s a very critical issue for us, especially if we do the parathyroid surgery. That’s something we’re most concerned about. The first symptoms that patients will notice will be a little tingling around their mouth, or often they’ll start getting muscle spasms. And that’s usually the first indication that your calcium levels may be critically low.
Dr. Linda Austin: The tingling around the mouth, is that at any particular time of day, or is that all the time?
Dr. Josh Hornig: It can be anytime. Usually, if someone’s had this surgery; the parathyroid surgery, and they get the tingling, I have them get a blood test to check their calcium levels as soon as possible.
Dr. Linda Austin: Any adverse consequences, or particular dangers, of having this surgery?
Dr. Josh Hornig: There are several important complications. Like any surgery, there’s always going to be a risk of bleeding, and a risk of infection, and you will have a scar on your neck. To alleviate most of those things, we use minimally invasive techniques. We’re very careful when we’re doing the surgery so that blood loss is almost minimal, if any at all. The scar is hidden in the crease in the neck, so it’s actually very imperceptible, given time.
The two major risks are the calcium levels dropping after the surgery. Instead of having high calcium levels, you would now have low calcium levels. The second is that there’s a very important nerve, the recurrent laryngeal nerve. This nerve is critically important in the movement of our voice box. If that nerve gets damaged, you’ll have a very hoarse voice, and that can be very detrimental in the long term.
Dr. Linda Austin: How common is it to have that problem?
Dr. Josh Hornig: The literature reports that to be about one to two percent. And that’s a fairly accurate number, if it’s a very experienced parathyroid surgeon. That number is probably much higher with someone who doesn’t do that surgery very often.
Dr. Linda Austin: So, obviously, it’s important to get someone who really knows what they’re doing when they’re doing this surgery.
Dr. Josh Hornig: Right. There’s an old saying that the most important localizing technique in parathyroid surgery is localizing a good parathyroid surgeon. That’s probably still true today.
Dr. Linda Austin: Tell us about who is on the team here, and what MUSC’s program in this area is.
Dr. Josh Hornig: I’m really excited about this. Our department, in ENT, has really taken a lead role in trying to minimize the impact to patients with their surgery. We are one of the few centers in the United States; one of the few centers in the world, that has two surgeons that can do this surgery. Dr. Lynch and I have both been doing this, and we believe, together, we have the most experience, in this type of surgery, in the United States.
Dr. Linda Austin: That’s pretty exciting.
Dr. Josh Hornig: Yeah, we’re very excited about it. And we’re trying to get the word out so people can see what we have to offer.
Dr. Linda Austin: What is the typical age of your patient that requires this surgery?
Dr. Josh Hornig: It varies quite a bit. Usually, it seems to be people in their forties and fifties when it starts to get picked up. And I think that’s because they’re starting to go for their annual physical more regularly and getting the blood test that picks up the calcium levels. In the United States, now, it’s very rare for people to come in with symptoms. It’s usually caught much earlier; before it actually starts causing a lot of problems.
Dr. Linda Austin: Dr. Hornig, thanks so much.
Dr. Josh Hornig: You’re very welcome.
If you have any questions about the services or programs offered at the Medical University of South Carolina, or if you’d like to schedule an appointment with one of our physicians, please call MUSC Health Connection at: (843) 792-1414.