Abstract
Normal parathyroid glands vary in macroscopic appearance, number, and location. Adequate surgical treatment of hyperparathyroidism often depends on identification of all glands, which requires precise knowledge of the normal anatomy and embryology of organs derived from the third and fourth branchial pouches. The following questions form the basis of surgical strategy: (a) Is this a normal parathyroid gland? (b) Where should the surgeon look for a normal gland? (c) How many parathyroid glands are there? (d) Where should the surgeon look for a missing gland? About 80% of patients have 4 glands. The upper pair is usually near the point where the recurrent nerve enters the larynx. The lower pair is more variable in location and may be found between the inferior thyroid artery and the thymus. Normal glands may be ectopically located along the path of embryologic migration, adjacent to or embedded in organs of similar origin.
Parathyroid hormone (PTH), vitamin D, and calcitonin maintain calcium levels which modify intestinal absorption, renal excretion, and bone turnover. PTH secretion responds promptly to calcium changes acting upon vitamin D synthesis, tubular reabsorption of phosphates, calcium renal excretion, and bone reabsorption. Vitamin D controls intestinal calcium absorption. Calcitonin stimulates bone accretion. Excess PTH tilts this balance toward hypercalcemia, hypercalciuria, and bone décalcification; hypercalcemia and detectable PTH levels coincide only in hyperparathyroidism.
In treating patients with hyperparathyroidism, delicate surgical technique is essential, but the ingenuity of the surgeon in developing a plan of action based on thorough knowledge of normal anatomy and embryology is the key to successful therapy.
Résumé
L'aspect macroscopique, le nombre et la position des glandes parathyroïdes normales sont variables. Le traitement chirurgical adéquat de l'hyperparathyroïdie dépend souvent de l'identification peropératoire de toutes les glandes: ceci exige une connaissance exacte de l'anatomie et de l'embryologie normales de ces organes dérivés des troisième et quatrième poches branchiales. Au cours d'une exploration cervicale pour affection parathyroïdienne, le chirurgien doit être capable de répondre aux questions suivantes: (a) Ceci est-il une parathyroïde normale? (b) Où faut-il, normalement, chercher les parathyroïdes? (c) Combien de parathyroïdes y a-t-il? (d) Où le chirurgien doit-il rechercher une parathyroïde manquante? Quelques 80% des patients ont 4 parathyroïdes. Les supérieures sont en général proches du point où le nerf récurrent pénètre dans le larynx. La localisation des inférieures est plus variable, en général entre l'artère thyroïdienne inférieure et le thymus. Les glandes en position ectopique sont localisées le long du trajet de migration au cours du développement, contre ou dans les organes qui ont la même origine.
L'hormone parathyroïdienne (PTH), la vitamine D et la calcitonine règlent la calcémie en agissant, par un délicat équilibre, sur l'absorption intestinale, l'excrétion rénale et la fixation osseuse. La sécrétion de PTH répond rapidement à toute modification de la calcémie par un effet sur la synthèse de vitamine D, la réabsorption tubulaire des phosphates, l'excrétion rénale du calcium et la fixation sur l'os. La vitamine D contrôle l'absorption intestinale du calcium. La calcitonine favorise la fixation osseuse. Tout excès de PTH entraîne une hypercalcémie, une hypercalciurie, une déminéralisation osseuse. Il n'y a que dans l'hyperparathyroïdie que l'hypercalcémie est associée à un taux élevé de PTH plasmatique.
Pour traiter l'hyperparathyroïdie, il faut une technique chirurgicale délicate et minutieuse, mais il faut aussi un plan d'action basé sur une connaissance complète de l'anatomie et de l'embryologie.
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Ayala, L.A. Anatomy and physiology of the parathyroids: A practical discussion for surgeons. World J. Surg. 1, 691–698 (1977). https://doi.org/10.1007/BF01555916
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DOI: https://doi.org/10.1007/BF01555916