Parathyroidectomy, parathyroid surgery

Overview

Parathyroidectomy is a surgical removal of one or more of the parathyroid glands or a tumor affecting these glands. The parathyroid glands are four small structures, each roughly the size of a grain of rice, located behind the thyroid gland at the base of the neck. They are responsible for producing parathyroid hormone, which is vital for maintaining proper calcium levels in the bloodstream and tissues. This hormone is essential for the effective functioning of nerves and muscles and for keeping bones healthy.

The surgery is commonly performed to address hyperparathyroidism, a condition characterized by overactive parathyroid glands. In many cases, removing just one gland is enough to manage the condition effectively. Parathyroidectomy is used to treat primary hyperparathyroidism and may also be recommended for secondary hyperparathyroidism when nonsurgical treatments are unsuccessful.

Types

Several surgical techniques are available for parathyroidectomy, each involving an incision that usually fades into a fine line:

• Minimally invasive surgery: This surgery typically is done when only one of the parathyroid glands is overactive. Using information from the imaging tests done before surgery, the surgeon locates and removes the overactive gland.
• Bilateral neck exploration: In this approach, the surgeon examines all four parathyroid glands and removes any that are overactive. This method may be necessary if the surgeon cannot locate a gland on the first side explored or if preoperative imaging is inconclusive or indicates multiple overactive glands. It is also preferred in cases where certain medical conditions suggest a higher likelihood of multiple overactive glands. Some surgeons opt for this method in all cases for thoroughness.

Reasons for undergoing the procedure

Parathyroidectomy is recommended if one or more of your parathyroid glands produces excessive amounts of parathyroid hormone, leading to hyperparathyroidism. This condition can result in elevated calcium levels in the blood, which can cause a range of issues. These problems include weakened bones, kidney stones, fatigue, memory difficulties, muscle and joint pain, frequent urination, and abdominal discomfort, among other symptoms.

• Primary hyperparathyroidism: This condition is frequently treated with surgery, especially when one or more parathyroid glands become overactive. This over-activity is often due to an adenoma, a non-cancerous growth in a parathyroid gland, or sometimes due to hyperplasia, where the glands are enlarged.
  Though rare, a cancerous tumor can also cause this condition. Surgery is typically recommended when elevated blood calcium levels from primary hyperparathyroidism lead to symptoms. If the condition develops before age 50, your healthcare provider might suggest surgery even if you are asymptomatic.
• Secondary hyperparathyroidism: These may also require surgical intervention in some cases. This form of the disorder arises due to another underlying medical condition, most commonly kidney disease. The elevated levels of parathyroid hormone are a response to insufficient calcium and vitamin D. While this condition is often managed with non-surgical treatments, parathyroidectomy might be recommended if symptoms persist despite treatment.

Risk

Parathyroidectomy is typically a safe procedure, though it does carry some risks, as with any surgery. Possible risks include:

• Infection
• Hematoma, which is a buildup of blood under the skin of the neck causing swelling and pressure
• Long-term low calcium levels resulting from the removal or damage of all four parathyroid glands
• Persistent or recurring high calcium levels if a parathyroid gland was not identified during the surgery or if another gland becomes overactive after the procedure
• Sore throat

Before the procedure

Before your parathyroid surgery, you may need to fast for a specified period. Your healthcare provider will provide detailed instructions regarding this. Additionally, arrange for a friend or family member to assist you with transportation home after the procedure.

To locate the overactive parathyroid gland or glands, one or more imaging tests may be used:

• Sestamibi parathyroid scan: This test involves an injection of sestamibi, a radioactive dye that is taken up by overactive parathyroid glands. A scanner detects the radioactivity to identify these glands. This scan may be combined with a computerized tomography (CT) scan to enhance the detection of any issues with the parathyroid glands.
• Ultrasound: Ultrasound imaging uses sound waves to produce pictures of the parathyroid glands and surrounding tissues. A small device called a transducer emits high-frequency sound waves and records the echoes that bounce back from the body’s structures. These echoes are then transformed into images displayed on a monitor. Ultrasound can also help identify thyroid nodules that might require treatment during the parathyroidectomy.
• 4D CT imaging: This advanced type of CT scan uses contrast dye to pinpoint the location of an overactive parathyroid gland, offering detailed and dynamic imaging.
• PET-CholineCT: This imaging study is used to locate parathyroid glands that other methods might not detect, particularly after a previous surgery has not been successful.

During the procedure

Parathyroidectomy is done under general anesthesia, which means you’ll be unconscious during the entire procedure. This type of anesthesia allows the surgeon to use nerve monitoring techniques to identify and safeguard the nerves that control your voice box.

Surgeons may use various techniques for parathyroidectomy, including traditional, minimally invasive, and scarless approaches. The traditional method involves making an incision on the neck, which the surgeon will place in a strategic location, such as a natural skin crease, to minimize visible scarring. Minimally invasive surgery targets only the overactive gland through a smaller incision. The scarless approach involves making an incision inside the mouth rather than on the neck. Your surgeon will review these options with you and explain what to expect on the day of your procedure.

For some minimally invasive surgeries, local anesthesia may be used, allowing you to remain awake during the procedure. You might experience some pressure and movement but should not feel pain. Local anesthesia is administered via injections near the surgical area. During the surgery, a blood test to measure parathyroid hormone levels is usually conducted to ensure that all overactive glands have been successfully removed.

After the procedure

After surgery, you can resume eating and drinking normally. Depending on the procedure, you might be able to go home the same day, though some cases may require an overnight hospital stay.

It’s common to experience some discomfort at the incision site, along with mild hoarseness and a sore throat from the anesthesia. Although rare, a hoarse or weak voice can occur due to nerve issues. If these symptoms persist, they are usually temporary but may last for weeks or longer. Should hoarseness continue, an examination of your vocal cords may be recommended.

Once home, you can typically resume your usual activities. Be sure to follow your healthcare provider’s guidance on when it’s safe to return to more strenuous activities like heavy lifting or intense sports.

You may have a scar at the base of your neck after surgery. Your healthcare provider might recommend using sunscreen to help minimize the visibility of the scar.

Your condition may require you to take calcium supplements for a brief amount of time. Your blood calcium levels will be maintained as a result, helping the remaining parathyroid glands to repair and adjust.

Outcome

Parathyroidectomy effectively cures nearly all cases of primary hyperparathyroidism and restores blood calcium levels to a healthy range. Symptoms related to elevated blood calcium often diminish or significantly improve after the procedure, improving your overall quality of life.

Post-surgery, the remaining parathyroid glands may need time to resume normal function, and calcium may be absorbed into the bones, potentially leading to temporary low calcium levels, known as hypocalcemia. Symptoms like numbness, tingling, or cramping can occur but typically resolve within days or weeks. Your healthcare provider may recommend calcium supplements to prevent this issue. While blood calcium usually stabilizes over time, in rare cases of persistent hypocalcemia, long-term calcium and possibly vitamin D supplements might be necessary.

After your parathyroidectomy, contact your healthcare provider if you experience:

• A fever exceeding 101°F (38.3°C)
• Pain that doesn’t improve with medication
• Difficulty swallowing
• Signs of infection at the incision site, such as redness, discharge, or increased warmth
• Symptoms of low calcium, including numbness, muscle cramps, or fatigue