Parathyroid Surgery–Patient information

Minimally Invasive Parathyroidectomy The parathyroid glands are part of the endocrine system and produces parathyroid hormone (PTH), which regulates the calcium level in the blood. When the calcium level is low, PTH acts on the bones, intestine, and kidneys to increase the calcium in the blood. When the calcium level is high, the PTH should be low. When the calcium level is normal, the PTH should be normal too. The relationship between calcium levels and PTH levels is called a negative feedback loop, meaning they have an inverse relationship. There are typically four parathyroid glands, one superior pair and one inferior pair on each side of the neck. Rarely, there can be 5 glands present. Normal parathyroid glands are 5 mm, about the size of a grain of rice and weigh between 20 and 40 mg. They are located on the back (posterior) side of the thyroid gland in the low part of the neck around the windpipe and voice box. The parathyroid glands can become overactive and overproduce PTH, causing an increase in blood calcium levels. This is called hyperparathyroidism. The most common cause over overproduction of PTH is a benign tumor called an adenoma. The adenoma is an enlarged parathyroid gland and usually weigh between 100 mg and 4 g but can be even larger. Usually there is just one adenoma but sometimes there can be two. Less commonly, overproduction is caused by hyperplasia or overgrowth of all four glands. Rarely, the cause can be cancer of a parathyroid gland. Elevated calcium levels due to hyperparathyroidism can cause many problems including general fatigue; neurologic symptoms such as irritability and lethargy; kidney problems such renal stones and excessive urination; bone and joint pain, muscle weakness, and decreased bone mineral density (osteopenia or osteoporosis); gastrointestinal problems like constipation and nausea. These symptoms are commonly referred to as “painful bones, renal stones, abdominal groans, and psychic moans.” When a patient has any of these signs or symptoms, surgery is recommended. In those who deny symptoms, surgery is recommended if the patient is high risk for developing future problems from hyperparathyroidism: age under 50, calcium levels greater than 10.5 to 11, or decreased kidney function. In those who are asymptomatic and do not have any of the above risk factors, non-surgical observation is usually advised. Minimally invasive parathyroidectomy implies that surgery is targeting one specific gland, thus limiting the length of incision and extent of dissection in the neck.

Traditional surgery involved larger incisions and exploration of all four glands on both sides of the neck. Current technology allows often allows us to identify the diseased gland prior to surgery, and therefore, to minimize the extent of surgery and operating time. Such technology includes the pre-operative neck ultrasound, sestamibi nuclear medicine scans, and specialized four-dimensional CT scan. Many times a patient will undergo a pre-operative injection with radioactive material. A diseased parathyroid gland will have increased uptake of this radioactivity and a probe is used intra- operatively to detect this uptake and localize this gland. Another tool used is intra- operative PTH level. Measuring PTH levels during surgery after removal of an involved gland also allows surgeons to ensure that all of the disease is treated. Parathyroid surgery is performed under general anesthesia, and involves an incision in the lower part of the neck in the midline. The size of the incision is usually only 3 cm in length and typically heals with only a faint scar. Occasionally a drain is placed in the wound if the surgeon is concerned about post-operative bleeding. The drain is usually removed 1-2 days after surgery. Overnight hospitalization is required if the patient’s calcium levels are low and need to be monitored. Risks of Parathyroidectomy Recurrent laryngeal nerve injury is a rare risk of surgery, occurring 1 out of 200 cases. The recurrent laryngeal nerves innervate the vocal cords, allowing the vocal cords to close and open, which is required for normal breathing and voice. There a two vocal cords, one left and one right, and each side is innervated by a laryngeal nerve. The nerves course through the thyroid gland as it travels to the voice box, or larynx. The nerves are identified during surgery in order to ensure preservation and safety. Rarely, the nerve can be injured during parathyroidectomy. This is often temporary and usually resolves in a matter of 6 weeks but may take up to 12 months. Injury may be permanent in some cases. If one vocal cord nerve is injured, the voice becomes breathy and hoarse. In the event of permanent injury, fortunately a normal voice can be restored with a vocal cord medialization procedure. If both the left and right vocal cord nerves are injured, this may cause difficulty breathing, which can be life threatening. A tracheotomy (breathing tube in neck) is needed in severe cases. Superior laryngeal nerve injury is also a rare risk. The superior laryngeal nerves innervate the top of the vocal cords and are responsible for fine-tuning the voice, especially for high pitches. Normal function of these nerves is vital for professional singers, but the nerves are not required for normal conversational speech. Hemorrhage or bleeding is a rare risk that may occur within several hours after surgery. This may cause progressive swelling in the neck and requires immediate drainage in the operating room. Severe cases can cause rapid airway swelling and difficulty breathing, which can be life threatening. If the surgeon is concerned about an increased risk of post-operative bleeding, a drain will be placed in the wound and is usually removed the next day.
Hypocalcemia and hypoparathyroidism are risks of parathyroidectomy. This is not a risk during a minimally invasive parathyroidectomy; however, if all four glands require exploration, normal glands may become “stunned.” This is usually temporary and lasts anywhere from a few days to 2 months. Rarely, parathyriodectomy my results in a permanently low calciumDuring this recovery time, your surgeon may place you on calcium supplements (and sometimes vitamin D) to prevent a drop in your blood calcium levels. Signs of a low calcium level include tingling and numbness around mouth and in fingertips, muscle spasms and cramping. If the level drops severely, heart arrhythmias can develop, which can be fatal. Unfortunately, on rare occasions the parathyroid glands do not recover. This requires lifelong calcium and vitamin D supplementation. The following BEFORE and AFTER instructions can help you obtain the best possible results from your surgery. If you have any questions, please call one of the nurses. Make sure your questions are answered before surgery. Before Surgery Tell your doctor all the medications and herbal supplements you are taking. This includes both prescription and over the counter medications. If your primary physician/specialist has placed you on Aspirin, Plavix or Coumadin please inform your surgeon for specific instructions. If you develop any illness during the two weeks prior to surgery, please notify our office immediately. Plan to spend 7 – 10 days away from work or school after surgery. Each individual’s recovery time will vary. Please postpone out of town plans for two weeks after surgery. Night Before Surgery DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT UNLESS INSTRUCTED TO DO SO BY THE ANESTHESIOLOGIST. IF YOU EAT OR DRINK ANYTHING AFTER MIDNIGHT, YOUR SURGERY WILL BE CANCELLED! Continue to drink fluids up until midnight. You may take blood pressure medications the morning of surgery with sips of water. Remove all nail polish, make-up and jewelry (watches, earrings, all body piercings, necklaces, etc). Arrange to have a responsible adult drive you to the surgery center and stay with you at home on the night of your surgery. That person MUST stay in the waiting room until you have been discharged back to them. (You are NOT allowed to drive yourself home)
After Surgery What to expect Most patients will be discharged home the same day after a short observation period in the recovery room. Occasionally, a patient will require overnight observation. You will have a small incision in the lower part of the neck, likely covered with steri-strip dressing. Pain level varies for each patient between mild and moderate for 3-7 days. Medications

  • Calcium Citrate or Calcium Carbonate: Your doctor will often prescribe calciumsupplements while you recover from surgery. Usually, you will be instructed to take Tums 1000 mg three to four times per day for the first week or longer.
  • Vitamin D Supplement (Calcitriol): Occasionally your doctor will place you on a vitamin D supplement called calcitriol for a week or longer.
  • Antibiotics: Your physician may or may not prescribe an antibiotic. If you are given a prescription, please take it as directed until you finish the supply. This is important in wound healing and in preventing infection. You will not need a refill.
  • Pain Medication: The pain medication that is prescribed is usually Tylenol based with a narcotic, so you may experience some drowsiness. You should not go to work or school, nor drive a car as long as you are taking the pain medication. Your pain medication should be taken as directed, but do not exceed the prescribed dose. If severe pain persists, please call the office.
  • You must eat something 5-10 minutes before taking narcotic pain medication to avoid vomiting. Food suggestions are yogurt, applesauce, and crackers.
  • Anti-nausea Medication: You may or may not have been given a prescription for anti-nausea medication, please take as directed. If you were not given a prescription and you experience nausea and/or vomiting, please call the office.
  • Avoid alcoholic beverages as long as you are taking prescription medications.
  • Please follow instructions given to you by your surgeon regarding Aspirin, Plavix or Coumadin.
  • Refills must be approved by your doctor. Plan ahead and allow the office 48 hours to refill your prescription. Be sure to mention any drug allergies, as well as the name and location of the pharmacy at the time of your refill request.Activities and Comfort Levels
  • Rest, with head slightly elevated on 2-3 pillows is encouraged for the first couple of days.
  • You may shower after 48 hours. If your incision is covered with steri-strips, please leave these in place – your doctor will remove these during your first follow-up visit.
  • During the first week, quiet indoor activities are recommended.
  • NO heavy lifting, straining, athletic activities or sports for 2 weeks.
  • A low-grade fever of 99.9-101.0 F is common. To help control your fever, drinkplenty of fluids. If the fever exceeds 101.5, call the office. Diet
  • You may have a sore throat for a few days after surgery. Slowly progress to a regular diet as tolerated.Follow-up Appointment and Labs: The doctor will want to see you 7-10 days after surgery. Please call the SWENT office at 505-982-4848 to schedule. Your doctor will likely give you a lab order form to have your calcium and PTH levels drawn the day of your first follow-up appointment. On your appointment day, please stop at the Physician’s Medical Center to have your labs drawn before you see your doctor. Call the doctor if you have any of the following:
  • ♦  Signs of low blood calcium. If you have any of the following, take 1000 mg ofTums, call your doctor or go to the Emergency Department immediately.
    • ♦  Tingling or numbness around mouth, hands, fingertips, and bottom of feet.
    • ♦  Muscle cramps occurring anywhere on body. Common sites include face andhands.
  • ♦  Signs of neck bleeding: Swelling on neck, difficulty swallowing, difficultybreathing, or difficulty talking. If you experience any of these symptoms, present to the Emergency Department immediately.
  • ♦  Fever of 101.5 degrees or greater.
  • ♦  Severe pain not relieved by medication.
  • ♦  Vomiting 2 or more times in one day, after the first 24 hours.
  • ♦  Welts, Hives or Rashes that appear after taking prescription medication(s).
  • ♦  Bleeding around the incision site
  • ♦  Increased swelling or pain in face or neck.
  • ♦  Redness at incision site.