Parathyroid glands are located in the neck, two on each side. These glands resemble a small piece of fat smaller than a little pea. The parathyroid gland is responsible for calcium metabolism in our body. This is regulated in part by a hormone called “parathyroid hormone” or “PTH” for short which is manufactured with in the gland. When calcium levels are low the parathyroid gland produces PTH and excretes it into the blood stream. The higher PTH level causes several changes to take place. One of these is to strip calcium from the bone and transfer it into the blood stream. The end result is an improved calcium level at the expense of the bone—in other words osteoporosis. Changes in the kidney can lead to kidney stones.

For unknown reasons different pathologic conditions within the parathyroid gland can develop. This typically leads to an uncontrolled excess production of PTH. When the abnormal gland(s) is removed, the problem is resolved. The PTH level falls to normal being controlled by the remaining regular functioning gland(s).

Techniques Used in Parathyroid Surgery

There are two main approaches for parathyroid surgery: unilateral (one side of the neck) and bilateral (both sides). Bilateral surgery is best for the patients who are at risk for multiglandular parathyroid disease, which occurs in about 3-4% of patients, or for the patients at risk for co-existing thyroid nodules, which occurs in about 20% of patients. It is important to note that inexperienced surgeons may only perform the unilateral approach when using local anesthesia, however, an experienced surgeon will be able to use both approaches under local or general anesthesia with very little difference between the two in terms of recovery time, hospital stay, incision size, duration of operation and complications. Most patients typically prefer the general anesthetic approach.

Intra-operative parathyroid hormone (PTH) monitoring is sometimes used for patients undergoing unilateral neck exploration. This technique is used under the premise that 3-5% of patients have a second parathyroid gland which is overactive but was not identified by sestamibi scanning. If there is a second overactive gland, the PTH level does not drop immediately after removal of the first gland and the surgeon examines the other glands to identify the adenoma.

The main benefit to this technique is that it eliminates the need for intra-operative frozen section, which confirms that the adenoma has been identified and removed. However, most experienced surgeons do not need frozen section, since they are able to easily identify most adenomas during surgery themselves. There are some technical difficulties with using this assay, such as false negative or false positive results.

It is important to note that surgeons who examine all four parathyroid glands under general or local anesthesia during the primary surgery, do not use intraoperative PTH assays.

Potential Complications

Persistent hypercalcemia (high calcium)

Hypocalcemia (low calcium)

Injury to the recurrent laryngeal nerve (voice function)

Voice changes

Bleeding

Infection

Scar

Difficulty swallowing

Frequently Asked Questions

If you need parathyroid surgery, it is important to know what to expect. The following are some of the most frequently asked questions:

What type of anesthesia will I have?

You are given the option of either general anesthesia or local anesthesia. Most patients opt for a general anesthetic. With general anesthesia you are completely asleep during the operation. With local anesthesia, your neck area is numbed, mild sedatives may be given to reduce anxiety, and you are awake during the operation.

How long will I be hospitalized?

Most patients are admitted to the hospital on the morning of their surgery. Although an overnight bed is automatically reserved for each patient, you can most likely go home the same day after a several hour observation period in the recovery room.

Will I have pain after the operation?

All operations involve some pain and discomfort. Our goal is to minimize this discomfort. At the time of operation, your surgeon will give you some numbing medicine which usually lasts about twelve hours. Although you should be able to eat and drink normally, the main complaint is pain with swallowing. Most patients take Tylenol® or Motrin® to keep them comfortable at home.

Will I have stitches?

Under normal circumstances there will be no visible stitches. A plastic surgical technique is used to minimize scaring. Therefore, no sutures will need to be removed. If there are stripes of tape across the wound, these will fall off on there own in about 10 days. The longer these tape strips are on the better the wound will look when healed.

Keep the wound dry for 2 days. After 2 days soap, water and shampoo can run over the wound without a problem. Pat dry.

Will I have a scar?

Yes. All surgery causes scarring, and how a patient scars is dependent on the individual. However, there are some techniques that surgeons use to minimize scarring. These techniques include smaller incision size, careful incision placement, and hypoallergenic suture material (to avoid inflammation). As a general rule, it is unusual for adults to have a noticeable scar after six months.

Can my voice change after surgery?

Your voice may go through some temporary changes with fluctuations in volume and clarity (hoarseness). Generally, it will be better in the mornings and “tire” toward the end of the day. This can last for variable periods of time, but should clear in 8-10 weeks at most.

Will I have any physical restrictions after my surgery?

Soaking the wound in water for the first two weeks is the only major restriction. Getting the wound wet in the shower is ok after the second day. In general, your activity level depends on how much discomfort you experience. Many patients have resumed golf or tennis within days after the operation. Most patients are able to return to work within a few days, and you are able to drive as soon as your head can be turned comfortably (this limitation is for driver safety). You must see us for a routine follow-up office visit 1-2 weeks after surgery.

When will I know whether the abnormal parathyroid glands were removed?

Since there is no way to predict this prior to surgery, this information will usually be provided as soon as you awake in the recovery room. The ultimate answer will come when blood tests document a normal calcium level.

What are the possibilities that anything else will be found or removed at surgery?

About 10-30% of patients have thyroid abnormalities that are found at the time of parathyroid surgery. These thyroid abnormalities can be managed most efficiently at the time of surgery and may require partial or, in some cases, total removal of the thyroid.

Do I need to have my parathyroid hormone monitored during surgery?

This is an area of controversy for endocrine surgeons. If all four parathyroid glands are going to be examined, intraoperative parathyroid hormone monitoring is not necessary. However, if you will be having the unilateral approach, then parathyroid hormone monitoring is often used.