PARATHYROID AND ADRENAL GLANDS Dr Zaeem dahla Consultant

PARATHYROID AND ADRENAL GLANDS Dr. Zaeem dahla Consultant General & Laparoscopic Surgeon

Parathyroid glands Learning Objective A-To understand the development &anatomy of parathyroid. B-TO understand the physiology, function & investigation of PT. C-To describe management , risks & complications of parathyroid surgery.

EMBERIOLOGY THE foramen caecum at the base of the tongue is a remnant of thyroglossal duct this hallow structure migrate caudally and pass in close continuity with, and some times through the developing hyoid cartilage. The PTGs develop from the 3 rid&4 th pharyngeal pouch. The thymus gland also develop from 3 rid pharyngeal pouch As it descend to superior mediastinum , in thorax it take with it the PTG which arise from 3 rid pharyngeal pouch take the inferior site in regards to it upper pouch. THYROID GLAND ; usually arise from the 4 th • pharyngeal pouch.

Surgical anatomy & physiology • The normal PTG weight up to 50 mg with charterstic orangebrown colour. • Most adult have 4 glands, 2 superior, 2 inferior , but may have more than 4 glands, . • Superior PTG usually constant in its position , while the inferior PTG have non fixed position. • Upper PTH glands found in a fat tissue above on the posterolateral border of the thyroid immediately above the point of entry of the inferior thyroid artery.

• The lower pair of PTG , more variable in position , are usually found at the lower pole of thyroid , but may be found anywhere along a line from this situation downwards to the upper pole of thymus. Approximately 5% of PTGs are found within the upper anterior mediastinum. each gland has small capsule and is supplied by a single leash of blood vessels , theses glands are usually lie outside thyroid gland capsule.

• Histology; • The stroma consists of rich sinusoidal capillary net work with islands of secretory cells , two type of cells. The ‘ chief ’ cells or principle cells are small with vesicular nuclei and poorly staining cytoplasm. ‘oxyphil ’ cell are less numerous and larger , with granular cytoplasm and deeply staining.

• FUNCTION. • Chief cells give P. T. H also called parathormone, the hormone released directly into the blood. the circulating level of this hormone can be measured by radioimmuno-assay. it is sufficiently reliable to distinguish between high and low levels.

• FUNCTION OF PARATHYROID HORMONE • Stimulate osteoclast activity, thereby increase bone resorption by mobilizing calcium and phosphate. • Increase the reabsorption of calcium by renal tubules; thus reducing urinary secretion of calcium • Augment the absorption of calcium from the gut. • Reduce renal tubular re absorption of phosphate , thus promoting phosphate urea.

• Calcitonin hormone • Was once thought to be the second parathyroid hormone , but is now known to be secreted by thyroid from the ‘parafolicular cells ‘ ( c cell) its action quite the opposite action of parathormone.

Disease of parathyroid glands Hypo parathyroidism Hyper parathyroidism

hypoparathyroidism • Parathyroid titany is a rare complication of subtotal thyroidectomy (less than 1%) • Symptoms usually appear on the 2 nd or 3 d post oprative day, and are temporary. • Permanent hypoparathyroidism, most commonly encountered following radical thyroidectomy , this require constant supervision and treatment. • Titany in newborn may occur within the first few days of life in the child born of a mother with un diagnosed hypo parathyroidism.

Clinical feature • The 1 st symptoms are tingling and numbness in the face , fingers, toes. • In extreme cases cramps in the hands and feet's are very painful , the extended fingers are flexed metacarpi- phalangeal joints with thumb strongly adducted. • This called ( capo pedal spasm)

• Spasm of respiratory muscle. • In infancy symptoms of titan may be mist taken for epilepsy , though there is no loss of consciousness. • Latent titan maybe demonstrated by : • # chvostek’s sign • # trousseau’s sign

Treatment • In acute cases the symptoms can be qiuckly and effectively relieved by slow iv injection 10 -20 ml of 10% of calcium gluconate , this can be repeated till the serum ca level has been established. • Oral vitamen D (increase ca absorption from GIT) and calcium lactate. • Initial dose 400000 units of calciferol may be followed by 100000 units , daily till serum ca level become normal.

Hyperparathyroidism • Symptoms of over activity of the para thyroid gland may result from single or multiple adenoma (85%) • Hyperplasia of all 4 glands 13% • Carcinoma more than 1%. • That whole glands enlarged, darker in color. Firmer and more vascular.

Clinical feature • Hyperparathyrodism rarely found in 1 st decade of life's. • More common in women than men. • Most commonly between the age 20 -60 y • The disease has been described as : bones , stones , abdominal groans and psychic moans

Parathormone increase Bone disease • • Jonits, bones pain density of bones change Otitis fibrosa cystica Bone cyst (jaw bones) Renal stone renal stone nephroclcinosis renal colic Abdominal groans nausea , vomiting, anorexia peptic ulcer pancreatitis Psychic moans tiredness personality

investigation • serum calcium upper limit (10. 9 mg/dl) • • serum phosphate lower limit (3 mg/dl) excretion of ca in urine. serum alkaline phosphatase. serum PTH.

Differential diagnosis • Secondary cancer in bones ( breast, prostate, bronchus, kidney, thyroid) • Carcinoma with endocrine secretion (bronchus , kidney, ovary) • Multiple myeloma • Vitamin d intoxication • Sarcoidosis • Thyrotoxicosis

treatment • Surgery is the only curative treatment • Pre operative treatment is not usually necessary. • Occasionally patient with hypercalcemic crisis need emergency treatment by fluids infusion and biphosphate therapy.