Parathyroid Gland Conditions We Treat
Types of Parathyroid Surgery
In this surgery, the single diseased parathyroid gland is identified pre-operatively by using localization studies, such as the sestamibi scan or a parathyroid ultrasound. Intraoperative PTH monitoring is used to confirm there are no other diseased parathyroid glands.
Minimally Invasive Radioguided Parathyroidectomy
This is a type of focused parathyroidectomy that uses radioactive material to assist in localizing the diseased parathyroid gland. On the morning of surgery, a small intravenous injection of Technetium 99m sestamibi is given to the patient. The radioactivity concentrates in the diseased parathyroid gland. In the operating room, the surgeon uses a hand held gamma probe to focus in on the identity of the diseased parathyroid gland for removal. Intraoperative PTH monitoring is used to confirm there are no other diseased parathyroid glands.
Bilateral Neck Exploration
Also known as an open parathyroidectomy, the bilateral neck exploration is the traditional surgical approach to hyperparathyroidism. In this surgery, usually the diseased parathyroid gland could not definitively be pre-operatively localized. Therefore, all four parathyroid glands must be located and assessed for disease. After the diseased parathyroid gland is removed, intraoperative PTH monitoring is used to confirm there are no other diseased parathyroid glands.
Four Gland Hyperplasia
It is rare to have all four parathyroid glands diseased. However, if that is the case, treatment options would include removing 3 ½ parathyroid glands with ½ parathyroid gland left intact or removing all four parathyroid glands and transplanting part of a parathyroid gland in the neck.
Parathyroid surgery is typically done with general anesthesia. You will have a breathing tube in place during the surgery, which is removed after surgery prior to you waking up. A bilateral neck exploration parathyroidectomy can take approximately 90 minutes. The focused parathyroidectomy and minimally invasive radio-guided parathyroidectomy usually completed in less time.
The University of Maryland Medical Center surgeons typically use incisions measuring approximately two inches in length hidden in a natural skin crease. Once the redness fades away, the incision will not be noticeable to most people.
Intraoperative PTH testing is used to check the blood parathyroid hormone level (PTH) during surgery. PTH is produced by the parathyroid glands and a diseased parathyroid gland will release abnormally high levels. Prior to surgery, the PTH level will be abnormally high. After the diseased parathyroid gland is removed, the PTH level will return to normal quite quickly. Monitoring the PTH level during surgery allows the surgeon to be certain that the diseased parathyroid gland was removed. If the level does not return to normal quickly, there may be another diseased parathyroid gland that needs to be removed, which can be done during this initial surgery.
Risks of Surgery
In the hands of an experienced parathyroid surgeon, parathyroid surgery is a safe procedure with few complications.
Bleeding in the Neck
As with any operation, there is always a chance of bleeding. The average blood loss for thyroid operations is usually small and the chance of needing a blood transfusion is extremely rare. However, bleeding in the neck is potentially life-threatening because as the blood pools, it can push on the windpipe or trachea causing difficulty breathing. Patients are observed overnight. If there is no sign of bleeding and the patient feels well, they will go home the next morning. Once at home, patients should watch for signs, such as difficulty breathing, a high squeaky voice, swelling in the neck that continues to enlarge, and a feeling that something bad is happening. If any of these symptoms happen, the patient should call 911 first and then their surgeon.
Hoarseness/Voice Change (recurrent laryngeal nerve injury)
The recurrent laryngeal nerves control the vocal cords and are located on either side of the trachea (windpipe) in the area where the parathyroid glands can be often found. Damage to a recurrent laryngeal nerve can cause you to lose your voice or become hoarse. Temporary hoarseness, voice tiring, and weakness can occur when one or more of the nerves are irritated during the operation or because of inflammation that occurs after the surgery. This usually gets better within a few weeks, but can take up to 6 months to resolve. Even in the rare chance of having a permanently hoarse voice, there are things that can be done to improve voice quality. An otolaryngologist or Ear, Nose, & Throat specialist can be very helpful in determining the specific problem and can perform different procedures to help improve voice quality.
Hypocalcemia (low blood calcium levels) may occur after thyroid and parathyroid surgery because the parathyroid glands may not function normally right after surgery and temporary hypocalcemia/hypoparathyroidism is common. The parathyroid glands are four small, delicate glands that measure about the size of a grain of rice. They are located near, or attached to, the thyroid gland and control the blood calcium levels. Each thyroid lobe has two parathyroid glands. After thyroid surgery and before you are discharged home your blood calcium will be checked. You will also be sent home with instructions to take supplemental calcium for the first week or two weeks after thyroid surgery. Hypocalcemia can cause symptoms such as numbness and tingling (especially around the lips and in the hands and feet) as well as muscle cramps. At your first post-operative visit, your blood calcium level will be checked and you may be weaned off the supplemental calcium prescribed after your surgery. Only one half functioning parathyroid gland is needed for calcium control. If all four parathyroid glands were injured or removed during surgery, the blood calcium levels can become lower than normal.
Seromas are fluid collections underneath the skin at an incision site that feel like fullness or swelling. When minor, they get usually disappear within a few weeks. If the seroma is large, it may need to drained by a surgeon.
If a post-operative infection develops, drainage of the infected fluid may be needed and antibiotics may be necessary. The neck is a clean area and infection is rare.
Preparing for Surgery
Prior to surgery, you will need to have a pre-surgical evaluation to be sure you are healthy enough to undergo surgery. This evaluation is done by our perioperative prep center (link) or your primary care physician. You will have blood work done and depending on your age and/or medical history may need other testing, such as an EKG or chest x-ray. If you have a history of significant cardiac or pulmonary conditions, you may need to get clearance from your medical specialist to continue with surgery.
The surgeon my need additional evaluations related to your specific thyroid or parathyroid condition to help plan for your surgery. These may include:
Ultrasound - An ultrasound is a painless study that uses sound waves to create an image of the thyroid and parathyroid.
- Fine Needle Aspiration - A fine needle is used to remove cells out of a thyroid nodule. These cells are used to differentiate a benign nodule from a malignant nodule.
- Fiber-Optic Laryngoscopy - vocal cord evaluation This is done by using a (small tube with a camera on the end) and allows the surgeon to determine how well your vocal cords are working. This evaluation is usually necessary if you have developed a hoarse voice or you have had previous neck surgery.
- CAT scan of the neck and chest - A CAT scan may be done to evaluate if a large thyroid is pushing on the trachea or growing down into the chest area.
- Sestamibi Scan - This nuclear medicine scan is used to localize diseased parathyroid glands prior to surgery.
Most patients will be eating, drinking, and walking around the night of their surgery. Typically, there is not a lot of pain involved with thyroid and parathyroid surgery. Rarely narcotic pain medication will be required, but it will be available to you if needed. Most patients only need acetaminophen (Tylenol) for discomfort. You will stay overnight for observation and be discharged to home usually by 11:00 AM the morning after surgery.
The incision is closed with dissolvable sutures internally and you will not be able to see them. On the outside, the incision will also be closed with either surgical glue or surgical paper tape called steri-strips. A light bandage consisting of a gauze pad and a clear plastic covering will be placed over your incision after surgery. This bandage may be removed 48 hours after you leave the hospital.
If you have steri-strips on your incision, leave them in place until they begin to fall off naturally. If they have not fallen off in 7-10 days, you may gently remove them. If glue was used, it will appear as a white crusty white or yellow material covering the incision. You may notice tiny pieces of yellow material on your washcloth when you gently clean you incision.
The incision will be slightly raised and there may be swelling and light bruising at the incision site. This is normal for several weeks after surgery and will resolve over time. You may also feel a sensation of swelling or firmness that will also resolve over time.
It is normal to experience numbness under your chin after surgery, especially around the incision. This will get better over time. However, if you feel numbness and tingling around your mouth or in your fingertips or toes call our office.
You may experience slight oozing of a watery, reddish color of fluid a day or two after surgery. This is normal. Please call the office if the drainage is thick and yellow (like pus), or you develop a temperature over 101.5F, or if your incision becomes red and warm.
You may feel a firm ridge directly over the incision. This is normal and will soften and go away when healing is complete usually in 3-6 months. All incisions are sensitive to sunlight. The ultraviolet light of the sun and tanning booths will darken the scar area in the first year. Always use sunscreen.
You may shower the day after surgery. Try not to get the bandage totally soaked. Once the bandage is off, it is still OK to shower. Still try not to totally saturate the incision. You should not go swimming or soak in a tub or hot tub for at least a week.
You may eat whatever you choose. You may prefer softer foods and liquids initially if you have a sore throat. Advance you diet as you see fit. Some patients experience minor changes in swallowing that improve over time. You may feel there is a lump in your throat when you swallow. This sensation will decrease with time.
This is normal to experience after surgery and will often last up to 5 days after surgery. Lozenges and a softer diet may be helpful until this resolves. You may also feel like you have phlegm in your throat and need to cough. This is due to the irritation of the tube in your windpipe during surgery. It should clear up in 4-5 days.
Your voice may be hoarse or weak at first because the surgery took place near the voice box but usually recovers within weeks. Some patients also notice a change in the pitch of their voices that affects singing. Rarely these changes are permanent.
You may experience stiffness/soreness in your neck, shoulder, or back and may experience tension headaches. These may take a few days or weeks to go away completely. You should not drive until you can comfortably turn your head from side to side. It is a good idea to gently perform neck exercises to help keep it from getting stiff - looking side to side, up and down or moving your head in a small circle. You may apply a warm compress or heating pad to your shoulder and back to alleviate stiffness.
Pain Management at Home
Take NSAIDS like ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve) or acetaminophen (Tylenol) for the first 3-5 days as needed. Take medication as directed on the medication container. To prevent acetaminophen overdose, do not take acetaminophen when you are taking the pain reliever - Percocet - that was prescribed on your discharge from the hospital. They both contain acetaminophen. If you take the Percocet or any other narcotic - DO NOT drive a car or drink alcohol.
Back to Normal Activities
Most patients return to their daily activities in a few days and work in about a week, with some limitations. Strenuous activity and heavy lifting should be avoided for at least two weeks.
CALCIUM SUPPLEMENT - Your body’s blood calcium level may fall after a total thyroidectomy or parathyroidectomy. The parathyroid glands that regulate your blood calcium levels may not function properly after surgery. This is common and usually temporary. You will receive specific instructions on hospital discharge on how much calcium you need to take. Symptoms of a too low calcium level include numbness and tingling in your hands, feet, and around your lips. Some patients experience muscle cramps. Typically you will take calcium carbonate 1250 mg one to three tablets a day. Do not take calcium carbonate within 1-2 hours of taking other medications. If any questions about drug interactions, be sure to ask the pharmacist or doctor. Some brands of calcium carbonate are Os-Cal 500 and Tums.
THYROID HORMONE - If you have had a thyroid operation, you may be prescribed a thyroid hormone replacement called Synthroid (levothyroxine is a generic form). You must take this medication every day and on an empty stomach. Take in AM when you first get up and wait to eat anything for 30 minutes to one hour. A blood test will be done in 6-8 weeks to ensure the dosage is correct.
VITAMIN D - You may be prescribed a Vitamin D supplement like Calcitrol (Rocaltrol) to help with calcium absorption on discharge also.
When to Notify Our Office at 410-328-6187
You should call our office if you experience the following symptoms:
- Fever with a temperature higher than 101.5.
- Difficulty swallowing
- Increase in pain at the incision that is not relieved by pain medication.
- Increased swelling, redness, or drainage from the incision.
- Numbness or tingling of fingers, toes, or around the mouth.
- Muscle cramps
If you have trouble breathing, call 911 immediately.
Your post-operative appointment will be scheduled for 1 or 2 weeks after your surgery. Please call 410-328-6187 to make your appointment.
Endocrine Surgery a specialty service provided by the Division of General and Oncologic Surgery. To make an appointment call our office at 410-328-6187.