Parathyroid

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Hyperparathyroidism

What are parathyroid glands?

There are usually four glands, each about the size of a grain of rice, attached to the back of the thyroid gland in the neck. The parathyroid monitor and control the calcium level in your blood. The most common problem with them is development of a benign tumor of one gland which can then produce uncontrolled amounts of parathyroid hormone, pulling calcium out of the bones and driving up blood calcium to dangerous levels. This is called hyperparathyroidism. It is extremely rare that these tumors are malignant, but it is not uncommon to develop more than one. In patients with longstanding kidney failure, all four glands can begin over-functioning.

What are the symptoms of hyperparathyroidism?

In about half of patients, there are none. The condition is identified on a routine blood calcium check. Those that do have symptoms report weakness and fatigue, depression or mental “fogginess,” bone pain, muscle soreness, constipation, frequent urination or nausea. Patients may develop kidney stones or osteoporosis leading to fractures. Progressive bone loss is the most dangerous problem with this condition.

How is it diagnosed?

Blood tests can identify the increased calcium. Your doctor will then often rule out other causes of high calcium such as certain medications, bone diseases, or the over-ingestion of calciumcontaining supplements. The proof that the issue lies with the parathyroid glands is finding elevated or high-normal levels of parathyroid hormone (PTH) in the blood when the calcium is too high. This indicates the glands are not shutting down in the face of elevated blood calcium as they should, and are considered over-functioning. When this happens, the cause is almost certainly a benign tumor called a parathyroid adenoma. Sometimes the enlarged gland can be seen on ultrasound. Other times a test called a Sestamibi Scan (a nuclear medicine study) may be ordered to find the abnormal gland. In some cases a second enlarged gland may be identified. It is not always necessary to order an imaging study before surgery; your surgeon will decide if they need the information.

If you have been found to have high blood calcium on more than one occasion, make sure your doctor checks your PTH level. Otherwise the condition may go undiagnosed for years.

What can be done when they produce too much hormone?

Medications can be used to temporarily drive down the calcium, but the only good treatment is removal of the abnormal gland(s). This is done with surgery. The tumor will not go away on its own, and the side effects of the elevated hormone worsen with time and may cause permanent damage.

What is parathyroid surgery like?

Most parathyroid surgeries are done as an outpatient. Occasionally your doctor may keep you in the hospital overnight. After any needed tests are done, your doctor will talk to you about the type of surgery that is best for you. The two main types are 4-gland surgery or focal surgery.

In 4-gland surgery, all four glands are identified and inspected. This requires usually a 1-2 inch incision across the base of the neck. Finding these tiny glands is often quite tedious and timeconsuming, so this type of surgery may take more than two hours on occasion. Enlarged gland(s) are removed and the normal-appearing ones may be biopsied to confirm they are indeed normal. The advantage of this surgery is that unsuspected abnormal glands may be discovered and thus a second operation later on avoided. Its main disadvantages are the larger incision, longer operating time, and the increased risk of disturbing or damaging other tissues in the neck.

Focal surgery requires imaging studies to identify the likely location of the enlarged gland(s). A smaller incision is made, often to one side of the neck. Sometimes this can be done with sedation and numbing medicine instead of general anesthesia. The goal of this surgery is to proceed directly to the abnormal gland and remove it without disturbing other tissues in the neck. Its advantage is that it is a lesser surgery with fewer risks, and sometimes takes less than an hour, but because only one or sometimes two glands are seen, it cannot detect unsuspected abnormal glands on the other side of the neck.

With either technique, the risks of surgery include bleeding, infection, temporary fluid buildup in the neck, infection, or permanent hoarseness if the vocal cord nerve is injured. There are all very unlikely events. Parathyroid surgery is usually quite safe and well tolerated. The 4-gland operation also has the tiny risk of removal of too much parathyroid tissue, which can lead to a lifelong requirement for calcium and vitamin D supplements. With both types of surgery, there is a risk of having to have a second operation later on if another gland becomes overgrown. This risk is somewhat higher, up to 10%, with the focal surgery.

What is the recovery like?

Most patients will go home the same day as their surgery. We recommend planning on several days of reduced activity to get over the soreness and tiredness associated with surgery. You should be able to take care of yourself during your recovery. We ask that you do not drive or plan on any commitments until you are pain-free and can turn your head without discomfort. Walking, stairs, eating, riding in a car, and other daily activities are usually unaffected. You will be given calcium and sometimes vitamin D supplements for at least the first week, as once the high hormone levels are corrected the bones will begin to take calcium back out of the blood to replenish what was lost. This can result in low levels of blood calcium. This may cause tingling or numbness in the hands, feet, or lips.

You will be seen in our office around a week later for a postoperative check, and usually released to normal activity at that point. At some point in the weeks following surgery, your surgeon or primary doctor will recheck your calcium and PTH to make sure things have returned to normal. In the long term, future calcium levels will be checked to make sure the condition has not returned in another gland.

Discharge Instructions for Parathyroid Surgery

Activity:

You will likely be discharged the day of your surgery. You may be up and around as you desire, but should avoid overly strenuous activity for several days. You may walk and climb stairs. You may resume normal activities after the first week. You may drive once you are off pain medication and are able to move and turn your neck easily.

Care for the incision:

If an outer bandage is placed over the incision, it may be removed the day after surgery. If you have white steri-strips on the skin, leave them on the incision until your follow up visit. The steri-strips may get wet. Surgical glue can get wet the day after surgery as well. Bruising or puffiness is normal; spreading redness is not.

Diet:

For the first 24 hours after surgery, you may not have much of an appetite or feel able to tolerate heavy foods. We encourage you to begin with a soft diet and to keep up with your liquids. As your appetite increases, and you are not having difficulty swallowing, you will find yourself eating normally. There are no restrictions- just eat what your system can tolerate.

Medication:

Unless you are told differently by your surgeon or primary doctor, you can take 400 mg ibuprofen every 4-6 hours, or 800 mg every 8 hours, for the first 3-5 days after surgery, for a maximum dose of about 2400 mg/day (refer to the label for specific dosing based on age and weight). It is best if you can take some food with this medication.

Tylenol is also acceptable to help with the baseline pain after surgery. It can be taken in conjunction with ibuprofen, and with your prescription (unless your prescription already contains acetaminophen--which is Tylenol). Be very careful not to exceed the dosage on the bottle. Taking more than 3 grams/day is not advisable.

Blood thinners should only be restarted after surgery according to the plan discussed with you by your surgeon or prescribing doctor before surgery. If this was not made clear to you, call our office.

All other medications should be resumed once you get home. We would suggest sleep aids not be used while you are on narcotic pain medications.

You may be given a prescription for or asked to take calcium. Please follow your instructions carefully; your calcium levels may be monitored, depending on the extent of your surgery. If you are not given a prescription for Calcium, please purchase Tums to have available at your home for you to take if necessary. Two TUMS with each meal (6 per day) is recommended.

Elimination:

Constipation is very common after surgery. We recommend staying well hydrated, and using Miralax, prune juice, or Milk of Magnesia for a few days until things are back to normal. If you are at all prone to constipation, or if you need several days of pain medicine, it may help to add Benefiber, Metamucil or similar bulk fiber agents for a few days as well. Do not let more than 48 hours go by without a bowel movement without starting the above medications. If they fail to help within another 24 hours, call our office.

What to look for:

You may notice some swelling or slight drainage (usually pink or reddish in color) or bruising around the incision. This is normal and not cause for concern. However, please call our office at 703-359-8640 immediately if you develop any of the following: difficulty breathing, tingling in your hands or face, difficulty speaking, difficulty swallowing, excessive drainage or bruising, redness or swelling around the incision, fever over 100F, or persistent nausea or vomiting.

Follow-up:

You may need your calcium level measured. If so instructed, please have this test done through your Primary Care Physician’s office, or at a lab specified by your insurance company. The test results should be faxed to us immediately at (703) 591-6105.

You will be seen in our office 7 to 10 days after your surgery. Prior to surgery, you should have made an appointment for your first post-operative visit. If for some reason that appointment was not scheduled, please call our office at (703) 359-8640 as soon as your return home to schedule your appointment.

Difficulties:

Please call us if any problems or questions arise. We can be reached any time, including evenings and weekends, by calling our office number (703) 359-8640.

When to Call Your Doctor:

  • Swelling at the incision site
  • Bleeding at the incision site
  • Warmth, fever, or tenderness (signs of infection)
  • A sore throat that continues beyond three weeks
  • Tingling or cramps in the hands, feet, or lips