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Parathyroidectomy

 
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Parathyroid glands behind the thyroid gland, front view
What are the parathyroid glands? 
A parathyroid gland is one of the endocrine glands, which make hormones to regulate physiological functions in your body. They regulate the balance of calcium in the body. Other endocrine glands are the thyroid glands, the pituitary, the adrenal glands, the pancreas, the testes, and the ovaries.

There are usually four pea size parathyroid glands. They are located in the neck behind the thyroid gland.


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A parathyroid gland on the side view of the thyroid gland

Hyperparathyroidisim means over activity of the parathyroid gland(s). This can abnormally raise the blood's calcium level (hypercalaemia).

Parathyroid adenoma is a single overactive and enlarged parathyroid gland causing hyperparathyroidisim. This is a benign or non-cancerous tumour.

Hypercalcaemia can manifest clinically with kidney stones, bone pain, osteoporosis and fractures without trauma, constipation, pancreatitis, stomach ulcers, fatigue and depression.

Hypoparathyroidisim means under activity of the parathyroid gland(s). This abnormally lowers the blood's calcium levels (hypocalcaemia).



Investigations

The diagnosis of hyperparathyroidism should be confirmed using lab tests. The abnormal parathyroid gland and its location is also identified prior to the surgery. Here are some of the possible investigations that can be performed if indicated:

  1. Blood tests including calcium level in the blood
  2. An ultrasound examination of your neck to identify the location of the abnormal parathyroid gland(s)
  3. Sesta-MIBI scan also helps identifying the location of the abnormal parathyroid gland(s)
  4. A CT or MRI scan - Only occasionally, computed tomography scans (CT scans), and/or magnetic resonance imaging (MRI) tests are required
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Parathyroidectomy


Parathyroidectomy is the removal of one or more of the parathyroid glands. It is performed under general anaesthesia.

Patients with kidney failure usually require the removal of all the parathyroid glands.

A blue dye (methylene blue) infusion into the blood may also be used to help locating the parathyroid glands prior to the surgery. This dye is mainly taken up by the parathyroid glands staining them blue.

The surgeon makes an incision in the front of the lower neck where a tight-fitting necklace would rest. The surgeon then mobilises the thyroid gland to identify and remove the parathyroid gland or glands with the disease. At the same time precaution is taken to identify and preserve the recurrent laryngeal nerve(s). The nerves that lie very near to the thyroid and parathyroid glands and serve the larynx or the voice box.

The diagnosis may be confirmed by sending the gland(s) to the pathology department for immediate microscopic examination (frozen section).

A drain (a soft plastic tube that drains fluid out of the area) may be placed before the incision is closed. The incision is usually closed with sutures (stitches). A dressing may be placed over the incision and the drain, if one is used.

Indications for parathyroidectomy

Parathyroidectomy is usually performed to treat hyperparathyroidism when other non-operative methods have failed to control hyperparathyroidism.

Hyperparathyroidism (abnormal over-functioning of the parathyroid glands) causes Hypercalcaemia (abnormally high levels of calcium in the blood).

Complications of parathyroidectomy

Bleeding - The risk of bleeding is slim and in many cases is very mild. However in some cases this may be severe, requiring return to the operating theatre to stop the bleeding. Rarely is a blood transfusion required.

Infection - As with any surgery when there is a “cut or wound”, there is a potential but slim risk for infection.

Damage to the recurrent laryngeal nerve(s) — These nerves pass very close to the thyroid and parathyroid glands and supply the vocal cords. Therefore swelling, stretching, or injury to the recurrent laryngeal nerve can lead to vocal cord immobility and can produce a hoarse or husky voice. This complication is uncommon and usually is a temporary.

Scar - The neck wound is in the skin crease line and usually heals very well with a good cosmetic result. Rarely patients develop a thick scar or keloid. Numbness or altered sensation of the neck skin can be expected.

Medication to control calcium levels in the blood- Despite removing the parathyroid gland(s) delicately with minimal tissue handling, the blood's calcium level can temporarily decrease or even increase. It is not uncommon for there to be a fall in the blood calcium level following surgery. (The remaining parathyroid glands are under active following surgery.) As a result, patients may need to take supplemental oral calcium for several days or weeks following surgery. The need for lifelong calcium replacement therapy is also a possibility for some patients specially if all the parathyroid glands are to be removed e.g. patient on renal dialysis, if so, it will be discussed with you prior to the surgery.

Further surgery- If after the surgery the elevated calcium levels in the blood fails to drop, a second procedure may be required to find and remove the remaining parathyroid gland(s) which were either left on purpose or were failed to be located at the time of the original surgery.

Expectation and advice following parathyroidectomy

  • After surgery, you may have a drain (a tiny piece of plastic tubing), which prevents fluid from building up in the wound. This is removed when drainage is minimal, usually in 24-48 hours after the surgery

  • You may have some discomfort and/or pain with swallowing. This is usually resolved within 24 to 72 hours

  • The level of calcium in the body will be monitored during the first 48 hours after the operation by obtaining frequent blood samples for laboratory analysis

  • Contact your doctor immediately if you experience numbness and tingling of the lips, arms, or feet, and or twitching of your facial muscles and spasms or severe cramps in your muscles. As these are symptoms and signs of low blood calcium and you may require calcium supplement or increased dosage if you are already on the calcium medication

  • A follow up appointment will be arranged for you to see your surgeon. You may also be followed up with your endocrinologist for long term monitoring of your blood calcium levels. The renal team may also follow you if you are a patient with kidney disease

  • You will usually be discharged home, two to three days after the surgery

  • Suture is removed approximately 7 days after surgery

  • If you take aspirin, please discuss this with your doctor, as you may need to avoid taking aspirin for a few days prior and after the operation. Aspirin can potentially increase the risk of bleeding

  • Tanning is discouraged for 6 months after surgery

  • You can usually resume most of your normal activities within one to two weeks.

Please note that the details in this section are for general information only. You should always discuss the risks, limitations and complications of your specific operation with your surgeon.