Parathyroidectomy

Overview

A parathyroidectomy is a surgical procedure to remove one or more parathyroid glands, often due to an overactive gland or the presence of a tumor. These small glands, located behind the thyroid at the base of the neck, play a crucial role in regulating calcium levels in the blood. Typically, most people have four parathyroid glands, but some may have more or fewer.

The parathyroid glands produce parathyroid hormone (PTH), which is essential for maintaining a proper calcium balance within the body. Calcium is a vital mineral required for the proper functioning of muscles and nerves and for keeping bones strong. PTH regulates the calcium in the bloodstream and within body tissues that need it for optimal performance.

Parathyroidectomy is often performed to treat hyperparathyroidism, a condition where one or more parathyroid glands are overactive. In many cases, removing just one gland is sufficient to manage the condition effectively, helping to restore normal calcium levels and prevent potential complications associated with high calcium.

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

Primary hyperparathyroidism occurs when one or more of the parathyroid glands become overactive, often due to a noncancerous growth called an adenoma. This overactivity leads to an excess of parathyroid hormone (PTH), which raises blood calcium levels. The increase in calcium can cause symptoms such as weak bones, kidney stones, fatigue, memory issues, muscle and bone pain, excessive urination, and stomach pain. Surgery, called parathyroidectomy, is the most common treatment for primary hyperparathyroidism, especially when blood calcium levels cause symptoms. Health care providers may recommend surgery even if no symptoms are present, especially if hyperparathyroidism develops before age 50.

Secondary Hyperparathyroidism

Secondary hyperparathyroidism is generally caused by another medical condition, such as kidney disease. In this condition, low calcium and vitamin D levels cause the body to overproduce PTH, leading to elevated blood calcium levels. Although secondary hyperparathyroidism can often be managed with treatments to improve calcium and vitamin D levels, surgery may be considered if symptoms persist. Parathyroidectomy, in such cases, can help lower PTH levels and alleviate associated symptoms when other treatments are insufficient.

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-Choline CT: 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 usually resume eating and drinking normally, and depending on the procedure, you may be able to go home the same day. However, some cases may require an overnight hospital stay. It’s common to feel some discomfort at the incision site and experience mild hoarseness or a sore throat due to the anesthesia. While rare, a hoarse or weak voice may occur because of nerve issues, but these symptoms are typically temporary, though they can last for several weeks. If hoarseness persists, your healthcare provider might recommend a vocal cord examination.

At home, you can generally return to most of your usual activities, following guidance from your healthcare provider on when to resume more strenuous tasks like heavy lifting or intense exercise. A scar may remain at the base of your neck, and using sunscreen could help minimize its visibility. Additionally, you may need to take calcium supplements for a short period to maintain proper blood calcium levels, supporting the remaining parathyroid glands as they recover 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