Surgical anatomy of the parathyroid glands - Uptodate Free 20/10/22 20:21

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Surgical anatomy of the parathyroid glands

Surgical anatomy of the parathyroid glands
Authors:
Melanie L Lyden, MD, MHPE
Tracy S Wang, MD, MPH

Julie Ann Sosa, MD, MA, FACS

Section Editor:
Sally E Carty, MD, FACS

Deputy Editor:
Wenliang Chen, MD, PhD

Literature review current through: Feb 2022. | This topic last updated: Aug 31, 2020.

INTRODUCTION — The parathyroid glands were first identified by Sir

Richard Owen in the Great Indian Rhinoceros in 1850 [1]. They were identified in humans by Ivar
Sandstrom, a Swedish medical student, in 1880 [2]. The first parathyroidectomy was reported by
Felix Mandl in 1929, 30 years prior to the isolation of human parathyroid hormone [3].

The success of the surgical management of parathyroid disease is based on accurate

biochemical diagnosis and the surgeon's understanding of the significant embryologic
variations in parathyroid anatomy. An expert knowledge of the unusual anatomic locations for

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enlarged parathyroid glands is crucial to operative success during both initial and reoperative
parathyroid surgical exploration. The wide range of parathyroid anatomic variations may make it
difficult to predict a patient's anatomy preoperatively.

Parathyroid anatomy is discussed here. The indications for parathyroidectomy, treatment of

multiglandular disease, and surgical techniques are discussed elsewhere. (See "Primary
hyperparathyroidism: Management", section on 'Candidates for surgery' and "Parathyroid
exploration for primary hyperparathyroidism", section on 'Focused parathyroid exploration'.)

FUNCTION — The parathyroid glands are usually in close approximation with,

but function independently of, the thyroid gland. The parathyroid glands produce parathyroid
hormone (PTH), which is one of the two major hormones modulating calcium and phosphate
homeostasis; the other hormone is calcitriol (1,25-dihydroxyvitamin D). PTH also stimulates the
conversion of calcidiol (25-hydroxyvitamin D) to calcitriol in renal tubular cells, thereby
stimulating intestinal calcium absorption. The function and regulation of PTH and the diagnosis
and management of hyperparathyroidism are discussed in detail elsewhere. (See "Parathyroid
hormone secretion and action" and "Primary hyperparathyroidism: Diagnosis, differential
diagnosis, and evaluation" and "Primary hyperparathyroidism: Management".)

EMBRYOLOGY — The parathyroid glands arise from endodermal epithelial

cells, in conjunction with the thymus (figure 1). The superior parathyroid glands are derived from
the fourth branchial pouch. These glands are closely associated with the lateral lobes of the
thyroid and have a short line of embryologic descent [4].

The inferior parathyroid glands are derived from the third branchial pouch. These glands are
closely associated with the thymus and have a longer line of embryologic descent, which leads
to more variability in their anatomic position [4]. Inferior parathyroids can be found as high in
the neck as the carotid sheath and can also be found in the anterior mediastinum or even the
pericardium. However, the majority of inferior parathyroids are found near the inferior pole of
the thyroid.

The locations of ectopic parathyroid glands are related to the common origins of parathyroid,
thyroid, and thymic tissue. The third branchial pouch contributes to thymus development as well
as parathyroid and thyroid development. Both the third and fourth branchial pouches also
contribute to thyroid development. (See "Surgical anatomy of the thyroid gland".)

SIZE AND LOCATION — Normal parathyroid glands are

approximately the size of a grain of rice or a lentil. Normal glands are usually approximately 5 by
4 by 2 millimeters in size and weigh 35 to 50 milligrams (picture 1). Enlarged parathyroid glands
can be 50 milligrams to 20 grams in weight, most typically weighing approximately 1 gram and 1
centimeter in size (picture 2).

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The appearance of parathyroid glands can vary considerably [5,6]. The color varies from light
yellow to reddish brown. Most parathyroid glands (83 percent) are oval, bean shaped, or
spherical, but they can also be elongated (11 percent). Other variations such as teardrop,
pancake, rod-like, sausage, and leaf-shaped parathyroid glands have been described [6].
Occasionally the glands are bilobated (5 percent) or multilobated (1 percent).

Most (84 percent) patients have four parathyroid glands, two superior and two inferior glands
[5]. Additional glands are found in 13 percent of patients and only three glands in a very small
number of patients (≤3 percent) [5]. The terms "superior" and "inferior" refer to a gland's
embryologic origin, rather than the gland's location in the neck. During parathyroid exploration,
deductive reasoning based on the embryologic origin of identified parathyroid glands helps the
surgeon identify missing glands (figure 2).

The parathyroids are usually in close association with the thyroid [5]. Although there is
significant variability in the position of the glands, they are usually symmetric. The superior
glands are symmetric in 80 percent of cases, and inferior glands are symmetric 70 percent of the
time [5].

Superior parathyroid glands — Normal superior parathyroid glands

are usually located on the posterior-lateral surface of the middle to superior thyroid lobe. They
lie under the thyroid superficial fascia, posterior to the recurrent laryngeal nerve, and can be
visualized by carefully dissecting the thyroid capsule in this region. These glands also can reside
inside the thyroid capsule, just superior and medial to the posterior tubercle of Zuckerkandl of
the thyroid lobe. (See "Surgical anatomy of the thyroid gland", section on 'Tubercle of
Zuckerkandl'.)

The recurrent laryngeal nerve is always anterior to the superior parathyroid gland. The superior
parathyroid glands are usually 1 to 2 centimeters cranial to the junction of the recurrent
laryngeal nerve with the inferior thyroid artery and within 1 centimeter of the entry point for the
recurrent laryngeal nerve into the ligament of Berry and the cricoid cartilage [5].

Superior parathyroid glands can be undescended or can be parapharyngeal, retropharyngeal, or

retrotracheal within the middle cervical/mediastinal compartment. Enlarged parathyroid glands
can travel straight down the tracheoesophageal groove or the retropharyngeal space into the
chest.

Inferior parathyroid glands — The two inferior parathyroid glands

reside in the anterior mediastinal compartment, anterior to the recurrent laryngeal nerve. They
are most often found in the thyrothymic tract, or just inside the thyroid capsule on the inferior
portion of the thyroid lobes.

Ectopic parathyroid glands — Ectopic parathyroid glands occur

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because parathyroid tissue may co-locate with tissues that have a similar embryologic
development. An ectopic parathyroid gland that fails to have full migration during normal
development is termed "undescended." The ectopic gland may be one of the four parathyroid
glands, or it may be a supernumerary gland. In one series of 102 patients with persistent or
recurrent hyperparathyroidism who required reoperation, ectopic glands were found in the
paraesophageal position (28 percent), in the mediastinum (26 percent), intrathymic (24 percent),
intrathyroidal (11 percent), in the carotid sheath (9 percent), and in a high cervical position (2
percent) [7]. These percentages will vary depending whether the ectopic gland is superior or
inferior in origin.

●Ectopic superior parathyroid glands – Most often a missing superior parathyroid gland will
originate in a normal position but is difficult to find because caudal growth has moved the body
of the adenoma to the paraesophageal or retroesophageal space. An ectopic superior
parathyroid gland may be undescended and located at the piriform sinus. Superior parathyroid
glands can be also be intrathyroidal, but less commonly than inferior parathyroid glands.

●Ectopic inferior parathyroid glands – Enlarged parathyroid glands can be undescended at the
carotid bulb. More typically they will be found lateral and inferior to the middle to lower thyroid
lobe adjacent to the thyrothymic tract, which extends inferiorly from the inferior thyroid poles.
They may be subcapsular or completely intrathyroidal or may reside within or in close proximity
to the cervical or anterior mediastinal thymus. Ectopic inferior parathyroid glands are most often
found in the thymus or mediastinum (9 percent) [8]. An undescended inferior parathyroid gland
may be located anywhere within the carotid sheath (2 percent). They can also be located
intrathyroidally (1 percent).

Supernumerary parathyroid glands — Supernumerary (more

than four) parathyroid glands occur in 2.5 to 15 percent of individuals [5,9]. The majority of
supernumerary glands are small, rudimentary, or divided. However, when enlarged, these
additional glands may be responsible for persistent hyperparathyroidism after failed
parathyroid exploration, especially in patients with secondary hyperparathyroidism or
hyperparathyroidism associated with familial syndromes [5,10,11]. In one series of 137 cases of
persistent hyperparathyroidism after parathyroidectomy, supernumerary glands were found in
15 percent of cases [9]. They can range from five to eight in number [6].

Supernumerary glands can reside anywhere from behind the thyroid down to and including
within the thymus, representing the line of descent of thymic tissue during embryologic
development. The most common location is within the thymus or in relation to the thyrothymic
ligament (two-thirds of cases) [6,11]. The remaining supernumerary glands are usually found in
the vicinity of the mid-thyroid lobe between two other glands.

BLOOD SUPPLY — In most patients, the inferior and superior parathyroid

glands will both be supplied by branches of the inferior thyroid artery. Each parathyroid gland

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usually has its own end-artery [4]. Most parathyroid glands have a single arterial supply (80
percent), some have a dual artery supply (15 percent), and a minority have multiple arterial
supply (5 percent) [12]. The venous drainage of the parathyroid glands consists of the superior,
middle, and inferior thyroid veins that drain into the internal jugular vein or the innominate vein.
(See "Surgical anatomy of the thyroid gland", section on 'Blood supply'.)

During thyroid surgery, the surgeon should try to preserve all of the parathyroid glands in situ
with adequate blood supply whenever possible. However, the blood supply may not be adequate
following dissection of the thyroid gland, and the parathyroids are not always clearly identified.
It can be difficult to make a reliable intraoperative determination of individual parathyroid
function, and patients may experience transient hypoparathyroidism despite having all four
parathyroid glands preserved.

●Superior parathyroid glands – The superior parathyroid glands receive most of their blood
supply from the inferior thyroid artery and also are supplied by branches of the superior thyroid
artery in 15 to 20 percent of patients. A superior parathyroid gland that is supplied by the
superior thyroid artery will usually be located in close proximity to the superior pole of the
thyroid. A subcapsular dissection on the posterior lateral surface can assist in the identification
of parathyroid glands.

●Inferior parathyroid glands – The inferior parathyroid glands receive their end-arterial blood
supply from the inferior thyroid artery. Therefore, gentle medial mobilization of the parathyroid
rim from the thyroid capsule and preservation of the lateral arteriole going to the parathyroid
gland are important for preserving functioning inferior parathyroid glands. Ligation of the
branches of the inferior thyroid artery close to the thyroid parenchyma and medial to the
recurrent laryngeal nerve may help preserve intact parathyroid vascularity.

MISSING PARATHYROID GLANDS — A missed

parathyroid adenoma is the most common cause for a failed initial parathyroid operation and
persistent hyperparathyroidism [13]. During exploration for primary hyperparathyroidism,
understanding the embryology and anatomy of the parathyroid glands will help determine
which one of the four parathyroid glands is missing or whether a supernumerary gland is
present. Surgical exploration for a missed or ectopic parathyroid gland is discussed in detail
elsewhere. (See "Parathyroid exploration for primary hyperparathyroidism", section on 'Surgical
management'.)

SUMMARY AND RECOMMENDATIONS

●The success of the surgical management of parathyroid disease is based on accurate
biochemical diagnosis and the surgeon's expert understanding of the significant embryologic
variations in parathyroid anatomy. Knowledge of the unusual anatomic locations for enlarged
parathyroid glands is crucial to operative success during both initial and reoperative parathyroid

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surgery. (See 'Introduction' above.)

●The superior parathyroid glands are derived from the fourth branchial pouch. The inferior
parathyroid glands are derived from the third branchial pouch. (See 'Embryology' above.)

●Most (84 percent) individuals have four parathyroid glands, two superior and two inferior
glands. The terms "superior" and "inferior" refer to a gland's embryologic origin, rather than the
gland's location in the neck. During parathyroid exploration, deductive reasoning based on the
embryologic origin of identified parathyroid glands helps the surgeon identify missing glands.
(See 'Size and location' above.)

●Ectopic parathyroid glands occur because parathyroid tissue may co-locate with tissues that
have a similar embryologic development. The ectopic gland may be one of the four parathyroid
glands, or it may be a supernumerary gland. (See 'Ectopic parathyroid glands' above.)

●Supernumerary (more than four) parathyroid glands may be responsible for persistent
hyperparathyroidism after failed parathyroidectomy. Supernumerary glands can reside
anywhere from behind the thyroid down to and including within the thymus, representing the
line of descent of thymic tissue during embryologic development. The most common location is
within the thymus or in relation to the thyrothymic ligament. (See 'Supernumerary parathyroid
glands' above.)

●In most patients, the inferior and superior parathyroid glands will both be supplied by
branches of the inferior thyroid artery. Each parathyroid gland usually has its own end-artery.
(See 'Blood supply' above.)

●A missed parathyroid adenoma is the most common cause for a failed initial parathyroid
operation and persistent hyperparathyroidism. Understanding the embryology and anatomy of
the parathyroid glands will help determine which one of the four parathyroid glands is missing
or if it is a supernumerary gland. (See "Parathyroid exploration for primary
hyperparathyroidism", section on 'Missing gland'.)

REFERENCES
1. Owen R. On the anatomy of the Indian Rhinoceros (Rh. Unicornis, L). Trans Zool Soc Lond
1862; 4:31.
2. Sandström I. On a new gland in man and several mammals (glandulae parathyroideae). Ups
Läk Förh 1880; 15:441.
3. Mandl F. Therapeutischer versuch bein einem falle von ostitis fibrosa generalisata mittels
exstirpation eines epithelk orperchen tumors. Zentrabl Chir 1926; 5:260.
4. Bliss RD, Gauger PG, Delbridge LW. Surgeon's approach to the thyroid gland: surgical
anatomy and the importance of technique. World J Surg 2000; 24:891.
5. Akerström G, Malmaeus J, Bergström R. Surgical anatomy of human parathyroid glands.
Surgery 1984; 95:14.

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Surgical anatomy of the parathyroid glands - Uptodate Free 20/10/22 20:21

6. Wang C. The anatomic basis of parathyroid surgery. Ann Surg 1976; 183:271.
7. Shen W, Düren M, Morita E, et al. Reoperation for persistent or recurrent primary
hyperparathyroidism. Arch Surg 1996; 131:861.
8. Richards ML, Thompson GB, Farley DR, Grant CS. Reoperative parathyroidectomy in 228
patients during the era of minimal-access surgery and intraoperative parathyroid hormone
monitoring. Am J Surg 2008; 196:937.
9. Carter WB, Carter DL, Cohn HE. Cause and current management of reoperative
hyperparathyroidism. Am Surg 1993; 59:120.
10. Arveschoug AK, Brøchner-Mortensen J, Bertelsen H, Vammen B. Supernumerary parathyroid
glands in recurrent secondary hyperparathyroidism. Clin Nucl Med 2002; 27:599.
11. Edis AJ, Levitt MD. Supernumerary parathyroid glands: implications for the surgical
treatment of secondary hyperparathyroidism. World J Surg 1987; 11:398.
12. Flament JB, Delattre JF, Pluot M . Arterial blood supply to the parathyroid glands:
Implications for thyroid surgery. Surgical and Radiologic Anatomy 1982; 3:279.
13. Jaskowiak N, Norton JA, Alexander HR, et al. A prospective trial evaluating a standard
approach to reoperation for missed parathyroid adenoma. Ann Surg 1996; 224:308.

Topic 2156 Version 19.0

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References

1 : On the anatomy of the Indian Rhinoceros (Rh. Unicornis, L)

2 : On a new gland in man and several mammals (glandulae parathyroideae)

3 : Therapeutischer versuch bein einem falle von ostitis fibrosa generalisata mittels exstirpation
eines epithelk orperchen tumors

4 : Surgeon's approach to the thyroid gland: surgical anatomy and the importance of technique.

5 : Surgical anatomy of human parathyroid glands.

6 : The anatomic basis of parathyroid surgery.

7 : Reoperation for persistent or recurrent primary hyperparathyroidism.

8 : Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and
intraoperative parathyroid hormone monitoring.

9 : Cause and current management of reoperative hyperparathyroidism.

10 : Supernumerary parathyroid glands in recurrent secondary hyperparathyroidism.

11 : Supernumerary parathyroid glands: implications for the surgical treatment of secondary

hyperparathyroidism.

12 : Arterial blood supply to the parathyroid glands: Implications for thyroid surgery

13 : A prospective trial evaluating a standard approach to reoperation for missed parathyroid

adenoma.

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