Parathyroid Surgery

Though their names are similar, the thyroid and parathyroid glands are entirely different glands, each producing distinct hormones with specific functions. The parathyroid glands secrete PTH, a substance that helps maintain the correct balance of calcium and phosphorus in the body. PTH regulates the level of calcium in the blood, release of calcium from bone, absorption of calcium in the intestine, and excretion of calcium in the urine. The parathyroid glands regulate calcium in your body by making more or less of a hormone called parathyroid hormone (PTH). The parathyroid glands constantly measure calcium levels in your blood.

If the calcium level gets too high, the normal glands sense this and stop production of PTH. This lowers the calcium in your body and returns your calcium levels to normal. Abnormal glands cannot regulate calcium balance.  Abnormal glands continue to produce PTH even when calcium levels are normal. This continues to raise the blood calcium levels even when it is already very high.

What is hyperparathyroidism?

Primary hyperparathyroidism is a disorder of the parathyroid glands, also called parathyroids. “Primary” means this disorder originates in the parathyroids: One or more enlarged, overactive parathyroid glands secretes too much parathyroid hormone (PTH). In secondary hyperparathyroidism, a problem such as kidney failure causes the parathyroids to be overactive. This publication focuses on primary hyperparathyroidism.

If the parathyroid glands secrete too much hormone, as happens in primary hyperparathyroidism, the balance is disrupted: Blood calcium rises. This condition of excessive calcium in the blood, called hypercalcemia, is what usually signals the doctor that something may be wrong with the parathyroid glands.

In 85 percent of people with primary hyperparathyroidism, a benign tumor called an adenoma has formed on one of the parathyroid glands, causing it to become overactive. Benign tumors are noncancerous. In most other cases, the excess hormone comes from two or more enlarged parathyroid glands, a condition called hyperplasia.

Very rarely, hyperparathyroidism is caused by cancer of a parathyroid gland.

This excess PTH triggers the release of too much calcium into the bloodstream. The bones may lose calcium, and too much calcium may be absorbed from food. The levels of calcium may increase in the urine, causing kidney stones. PTH also lowers blood phosphorus levels by increasing excretion of phosphorus in the urine.

Why are calcium and phosphorus so important?

Calcium is essential for good health. Calcium is a critical factor in maintaining good strong bones. We need to maintain a large store of calcium in our bones. Abnormal parathyroid glands begin to “steal” calcium from the bones rather than leaving a healthy reservoir. This can lead to thinning of the bones (osteopenia or osteoporosis) and premature fracture.

The second very important role for calcium in the body is its job in the central nervous system. Calcium helps regulate brain function and the transmission of signals along our nerves. Abnormal calcium results in difficulty with concentration, memory and depression to name a few.

What causes hyperparathyroidism?

In most cases doctors don’t know the cause. The vast majority of cases occur in people with no family history of the disorder.

How common is hyperparathyroidism?

In the United States, about 100,000 people develop the disorder each year. Women outnumber men two to one, and risk increases with age. In women 60 years and older, two out of 1,000 will develop hyperparathyroidism each year.

What are the symptoms of hyperparathyroidism?

A person with hyperparathyroidism may have severe symptoms, subtle ones, or none at all. Increasingly, routine blood tests that screen for a wide range of conditions, including high calcium levels, are alerting doctors to people who have mild forms of the disorder even though they are symptom-free.

When symptoms do appear, they are often mild and nonspecific, such as a feeling of weakness and fatigue, depression, or aches and pains. With more severe disease, a person may have a loss of appetite, nausea, vomiting, constipation, confusion or impaired thinking and memory, and increased thirst and urination. Patients may have thinning of the bones without symptoms, but with risk of fractures. Increased calcium and phosphorus excretion in the urine may cause kidney stones.

How is hyperparathyroidism diagnosed?

Hyperparathyroidism is diagnosed when tests show that blood levels of calcium and parathyroid hormone are too high. Other diseases can cause high blood calcium levels, but only in hyperparathyroidism is the elevated calcium the result of too much parathyroid hormone. A blood test that accurately measures the amount of parathyroid hormone has simplified the diagnosis of hyperparathyroidism.

Once the diagnosis is established, other tests may be done to assess complications. Because high PTH levels can cause bones to weaken from calcium loss, a measurement of bone density can help assess bone loss and the risk of fractures. Abdominal images may reveal the presence of kidney stones and a 24-hour urine collection may provide information on kidney damage and the risk of kidney stone formation.

How is hyperparathyroidism treated?

Surgery to remove the enlarged gland (or glands) is the main treatment for the disorder and cures hyperparathyroidism in 95 percent of operations. There are two main approaches to parathyroid surgery, traditional and directed.

Directed surgery allows a smaller incision, quicker recovery, and no hospitalization.

Prior to surgery, the diseased parathyroid glands are attempted to be found (localized) in order to identify which side of the neck contains the diseased gland. . This is accomplished by a neck ultrasound and a nuclear medicine sestamibi scan. If imaging tests are negative (as high as 20% depending on the patient’s disorder and the quality of the imaging tests) a focused approach is not possible and traditional surgery is necessary.

Directed Parathyroid Surgery

This is the more common surgery being performed today. This approach involves a small (2 to 3 cm) incision in the neck in order to remove the diseased parathyroid gland. For a directed approach, the diseased parathyroid gland needs to be localized (found) prior to surgery.  . In order for the focused approach to be successful, additional intraoperative (during surgery) monitoring is also necessary in order to confirm that a patient is cured of their disease following removal of the single diseased parathyroid gland (an adenoma). The intraoperative PTH assay is used to confirm that PTH (parathyroid hormone) blood levels decrease an appropriate amount after the removal of the adenoma to indicate cure. If PTH levels do not drop to normal during a directed operation, it is usually indicative of other overactive parathyroid glands or hyperplasia. Directed surgery may need to be converted to traditional parathyroid surgery, in these cases.

Traditional Parathyroid Surgery

This is the older approach to parathyroid surgery which involves a bilateral (both sides of the neck) exploration for the removal of diseased parathyroid glands. Bilateral surgery is most often required for patients suspected of having multiglandular parathyroid disease (hyperplasia), those who have co-existing thyroid nodules needing removal, or in initially focused operations where it becomes necessary to perform a bilateral procedure due to disease in the opposite neck (when PTH levels do not fall after removal of a single gland). Preoperative imaging tests for parathyroid localization are not absolutely necessary but may be recommended by your surgeon. An intraoperative PTH assay (test of parathyroid hormone levels) may be used as well to confirm success of surgery.

What Can Happen if I Decide NOT to Have Parathyroid Surgery?

Hyperparathyroidism poses a long-term threat to your bones — and your general health. The more hyperactive the parathyroids are, the more calcium your bones lose. Calcium bone loss increases, the longer the diseased parathyroid glands remain in your body.  The result may be osteoporosis. This condition can make bones so brittle and weak that even normal stresses to bones can cause fractures due to bone weakness.

Your body is also at a higher risk of developing kidney stones with hyperparathyroidism. The extra calcium being pulled into your blood will need to leave your body through the kidneys. This may lead to stones.  Stones also increase the risk of kidney damage, bleeding and infection.

High calcium levels cause may cause symptoms of fatigue, loss of energy, irritability, and confusion.

Do All Patients with Hyperparathyroidism Require Surgery?

Some patients who have mild disease may not need immediate treatment, according to panels convened by the National Institutes of Health (NIH) in 2002. Patients who are symptom-free, whose blood calcium is only slightly elevated, and whose kidneys and bones are normal may wish to talk with their physicians about long-term monitoring. In the 2002 recommendation, periodic monitoring would consist of clinical evaluation, measurement of serum calcium levels, and bone mass measurement. If the patient and physician choose long-term follow-up, the patient should try to drink lots of water, get plenty of exercise, and avoid certain medications.

Are there any complications associated with parathyroid surgery?

Surgery for hyperparathyroidism is highly successful with a low complication rate when performed by surgeons experienced with this condition. About 1 percent of patients undergoing surgery experience damage to the nerves controlling the vocal cords, which can affect speech. One to 5 percent of patients lose all their parathyroid tissue and thus develop chronic low calcium levels, which may require treatment with calcium or vitamin D. The complication generally occurs when operating for hyperplasia rather than an adenoma since more extensive surgery is needed in these cases.

After Surgery

How long does surgery last?

The duration of the actual surgical procedure varies between 45 minutes and 3 hours, depending on the number of the glands that need to be removed. Each time a gland is removed a PTH level must be checked, which takes approximately 45 minutes, in order to ensure a curative surgery.

How long is the hospital stay?

Directed parathyroidectomy can be performed as an out-patient procedure requiring a few hour stay in the hospital. A more extensive parathyroidectomy usually requires an overnight hospital stay.

How long does it take for my incision to heal?

Neck incisions heal rapidly.  They are watertight in about 24-36 hours allowing you to shower carefully.  The incision normally heals fully within a few weeks.  There is also swelling and a feeling of firmness under the incision that may last for a couple of months.
Most scars are most noticeable 1-2 months after operation and gradually become less so after several months.  Until that time, you may notice the color is redder than surrounding skin.  This is normal and will improve.  However, this skin is sensitive to sun so make sure to cover the incision with sunscreen when outdoors for extended periods of time.

When can I go back to work?

Convalescence after parathyroidectomy is usually short but depends on the extent of your operation. Many patients return to an active work schedule within days after directed parathyroidectomy, however it may require up to 1 week to return to work after extensive neck exploration for parathyroidectomy. Consultation with your surgeon will determine when you can return to work after parathyroidectomy.