Parathyroidectomy

Overview

Parathyroidectomy (pair-uh-thie-roid-EK-tuh-me) is surgery to remove one or more of the parathyroid glands or a tumor that's affecting a parathyroid gland.

Parathyroid (pair-uh-THIE-roid) glands are four tiny structures, each about the size of a grain of rice. They are located behind the thyroid at the bottom of the neck. These glands make parathyroid hormone. That hormone helps keep the right balance of calcium in the bloodstream, as well as in body tissues that need calcium to work correctly. Parathyroid hormone is essential for nerves and muscles to work properly and for bones to be healthy.

Parathyroidectomy often is done to treat overactive parathyroid glands, a condition called hyperparathyroidism (hi-pur-pair-uh-THIE-roy-diz-um). In many cases, only one of the parathyroid glands need to be removed to effectively treat hyperparathyroidism.

Why it's done

You may need this surgery if one or more of your parathyroid glands makes too much parathyroid hormone (hyperparathyroidism). Hyperparathyroidism can cause you to have too much calcium in your blood. That can lead to a number of problems, including weak bones, kidney stones, fatigue, memory problems, muscle and bone pain, excessive urination and stomach pain, among others.

Primary hyperparathyroidism

Surgery is most often used to treat primary hyperparathyroidism. It happens when one or more of the parathyroid glands is overactive. The most common cause of this overactivity is an adenoma — a growth in a parathyroid gland that is not cancer. It can also occur when the parathyroid glands are enlarged (hyperplasia). A cancerous tumor is a rare cause of primary hyperparathyroidism.

When the rise in blood calcium caused by primary hyperparathyroidism leads to symptoms, surgery is often needed to lower the amount of calcium in the body. If you develop primary hyperparathyroidism before age 50, your health care provider may suggest you have surgery even if you don't have any symptoms.

Secondary hyperparathyroidism

Another form of the disorder, called secondary hyperparathyroidism, sometimes requires surgery. Secondary hyperparathyroidism develops as a result of another medical condition, most often kidney disease. Parathyroid hormone is elevated as a response to low levels of calcium and vitamin D. This often can be treated without parathyroid surgery. If symptoms remain after treatment, then parathyroidectomy may be advised.

Risks

Parathyroidectomy is generally a safe procedure. But as with any surgery, it carries a risk of complications.

Potential problems that could happen after this surgery include:

• Infection
• A collection of blood (hematoma) under the skin of the neck that causes swelling and pressure
• Long-term low calcium levels due to removal of or damage to all four parathyroid glands
• Persistent or recurrent high calcium levels due to a parathyroid gland that could not be found during surgery or another parathyroid gland that becomes overactive after surgery

How you prepare

You may need to avoid eating and drinking for a certain period of time before surgery. Your health care provider will give you specific instructions. Before your surgery, ask a friend or family member to help you get home after the procedure.

What you can expect

Before the procedure

Imaging tests

One or both of these imaging tests may be used to locate the parathyroid gland or glands that are overactive:

• Sestamibi parathyroid scan. For this scan, you're given a shot of sestamibi into a vein. Sestamibi is a radioactive dye that is absorbed by overactive parathyroid glands. It can be found by a scanner that detects radioactivity. Computerized tomography (CT) scanning may be combined with the sestamibi scan to help make it easier to find problems with the parathyroid glands.
• Ultrasound. Ultrasound uses sound waves to create images of your parathyroid glands and surrounding tissue. A small device held against your skin (transducer) sends out high-pitched sound waves and records the sound wave echoes as they reflect off structures inside your body. A computer converts the echoes into images that can be seen on a screen. Ultrasound also can be used to identify thyroid nodules that may need treatment during a parathyroidectomy.
• 4D CT imaging. This is a type of CT scan that can be used to help find the location of an overactive parathyroid gland. It uses contrast dye to show the parathyroid gland.
• PET-Choline CT. This is a study that may be done to locate parathyroid glands that cannot be found with other imaging. It is most commonly used after a previous surgery that has failed.

During the procedure

In most cases, parathyroidectomy is done using general anesthesia. This means you won't be conscious during the procedure. General anesthesia allows the surgeon to use nerve monitoring during the procedure to assist in identifying the nerves that go to your voice box.

In some cases of minimally invasive surgery, you may need only local anesthesia, so you're awake during the procedure. You may feel some pressure and movement, but you shouldn't feel pain. Local anesthesia is given with one or more injections near the surgery site.

A blood test to measure parathyroid hormone typically is done during surgery. The results are used to help confirm that all of the overactive glands have been removed.

There are several surgical approaches that can be used for parathyroidectomy. Each of these surgeries involves an incision that often 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 surgery, the surgeon looks at all of the parathyroid glands and removes the ones that are overactive. It may be done when a surgeon can't find a parathyroid gland on the side explored first. It also may be done if the imaging tests before surgery don't show an overactive parathyroid gland or show more than one overactive gland. Some medical conditions increase the risk for more than one overactive parathyroid gland, and a bilateral exploration may be done in those cases. Some surgeons may prefer to use this approach in all cases.

After the procedure

You may be able to leave the hospital the same day as the surgery. You might notice some discomfort at the incision site, or mild hoarseness and a sore throat from the anesthesia. A hoarse or weak voice from a nerve problem is very rare. If your voice is hoarse or weak after surgery, it doesn't necessarily mean there's permanent damage. These symptoms are often short term, but they can last several weeks or more. If hoarseness doesn't improve, you may need to have your vocal cords examined.

You'll be able to eat and drink as usual after surgery. Depending on the type of surgery you had, you may be able to go home the day of your procedure. In some cases, you may need to stay overnight in the hospital.

When you go home, you can usually return to your regular activities. Follow your health care provider's instructions on when you may return to vigorous activities, such as heavy lifting or strenuous sports.

After surgery, you may have a scar at the base of your neck. Your health care provider may advise using sunscreen to help keep the scar from being noticeable.

Results

Parathyroidectomy cures almost all cases of primary hyperparathyroidism and returns blood calcium levels to a healthy range. Symptoms caused by too much calcium in the blood may go away or greatly improve after this procedure.

After parathyroid glands are removed, the remaining parathyroid glands may take some time to work properly again. This, along with uptake of calcium into bones, can lead to low levels of calcium — a condition called hypocalcemia. You may have of numbness, tingling or cramping if your calcium level gets too low. This usually lasts only a few days or a few weeks after surgery. Your health care provider may advise that you take calcium after surgery to prevent low calcium. Typically, blood calcium eventually returns to a healthy level. Rarely, hypocalcemia may be permanent. If so, calcium supplements, and sometimes vitamin D, may be needed long term.