General Background

Hyperparathyroidism is a condition in which one or more of parathyroid glands over-produce parathyroid hormone. The parathyroid glands are small glands located adjacent to the thyroid gland in the neck, and they secrete a hormone responsible for the regulation of the body's calcium levels. There are typically four glands in total, two on each side. Elevated parathyroid hormone can cause an elevation in the blood calcium levels. Elevated calcium levels can cause several problems, including kidney stones, osteoporosis, body weakness, abdominal cramping/pain, and behavioral/mood changes. The most common cause of hyperparathyroidism is a parathyroid adenoma, where one of the parathyroid glands has become hyperfunctional. Occasionally hyperparathyroidism is secondary to parathyroid hyperplasia, where all of the glands are moderately hyperfunctional. The diagnosis of hyperparathyroidism is made by blood tests of serum calcium and parathyroid hormone levels. Preoperative imaging studies, such as ultrasound, CT scans, and nuclear medicine scans, can help localize adenomas.

The Procedure

The procedure to remove a parathyroid adenoma is performed under general anesthesia and takes approximately one to two hours; for four-gland hyperplasia, the procedure may take slightly longer. A horizontal incision is made in the neck, typically in a natural skin crease to minimize the appearance of any scar after surgery. The adenoma is carefully dissected away from surrounding important structures, and once removed, the deeper layers of the wound and the skin are then sutured closed. In the case of four gland hyperplasia, 3 and a half gland are removed from the body, while half of one gland is reimplanted in a forearm or shoulder muscle to allow for some residual production of parathyroid hormone. Occasionally a small drain is placed in the wound- this drain is typically removed in one to two days after surgery.

After Surgery

After spending several hours in the recovery area, you will be discharged home. Pain associated with the procedure is typically mild. Most patients often state the worst sensation after surgery is a sore throat, which is caused by the breathing tube placed in the airway during surgery. This sensation usually resolves after several days. If a drain has been placed during surgery, you will return to the office the next day to have it removed. Blood calcium levels will be checked once or twice after surgery to ensure that they remain stable. Approximately one week after surgery, the skin sutures are removed.

Risks of Surgery

There are several risks associated with parathyroid surgery. One of the important structures located near the thyroid and parathyroid gland is the recurrent laryngeal nerve. There is a nerve on both the right and left sides, and each is responsible for the movement of the vocal fold in the larynx, or voice box, on that specific side. Damage to the nerve during surgery can cause decreased movement or paralysis of vocal fold on that side, which can result in hoarseness or loss of voice. The risk of this complication is approximately 2 percent. When injury does occur to the nerve, the resulting hoarseness is usually temporary and gradually resolves over time. On the occasions that the voice does not improve, adjunctive procedures can be performed to improve the quality of the voice.

Another risk is hypocalcemia, or low blood calcium levels, after surgery. This occurs because the bones, which have been in a state of calcium depletion with the elevated parathyroid hormone levels, reabsorb calcium from the blood. In addition, the non-adenomatous glands often have decreased function compared to the adenoma, and it may take some time for the function to return back to normal. Low calcium levels can cause fatigue, muscle tightness and cramping, and in severe cases, EKG changes and seizures. Fortunately the rate of temporary hypoparathyroidism (low parathyroid hormone) is very low, and the incidence of permanent hypoparathyroidism is exceedingly rare. After surgery, your blood calcium levels will be checked to monitor for any signs of hypoparathyroidism. You may be started on oral calcium and Vitamin D (a vitamin also involved in calcium regulation) supplementation after surgery in cases of temporary hypoparathyroidism. The risk of temporary hypoparathyroidism is 10 to 20 percent , while the risk of permanent hypoparathyroidism is less than 1%. Once the parathyroid glands have returned to normal function, you will be weaned off the calcium and Vitamin D. In cases of permanent hypoparathyroidism, you would need to remain on daily calcium and Vitamin D supplementation. The risk of bleeding after surgery is very low, typically less than 1%. If any sudden swelling associated with pain or difficulty breathing is noted, immediate evaluation is required. This risk is minimized by the avoidance of any heavy lifting, strenuous activity, straining, or the use of blood-thinning products such as aspirin or NSAIDS for two weeks after surgery. Infection after surgery is a rare complication and is managed by oral antibiotics. Scarring from the surgery is very minimal; often the scar is so well hidden in skin creases that they are virtually unnoticeable. If you have prior history of keloids or hypertrophic scars, however, you may be at risk for larger-than-normal scar formation.