Thyroid & Parathyroid Surgery

What is a Parathyroidectomy?

Parathyroidectomy is surgery to remove one or more of the parathyroid glands or a tumour that's affecting a parathyroid gland.

Parathyroid glands are four tiny structures, each about the size of a grain of rice. They are located behind the thyroid at the bottom of the neck. These glands make parathyroid hormone. That hormone helps keep the right balance of calcium in the bloodstream, as well as in body tissues that need calcium to work correctly. Parathyroid hormone is essential for nerves and muscles to work properly and for bones to be healthy.

Parathyroidectomy often is done to treat overactive parathyroid glands, a condition called hyperparathyroidism. In many cases, only one of the parathyroid glands need to be removed to effectively treat hyperparathyroidism.

Why is this procedure performed?

You may need this surgery if one or more of your parathyroid glands makes too much parathyroid hormone (hyperparathyroidism). Hyperparathyroidism can cause you to have too much calcium in your blood. That can lead to a number of problems, including weak bones, kidney stones, fatigue, memory problems, muscle and bone pain, excessive urination and stomach pain, among others.

Primary hyperparathyroidism

Surgery is most often used to treat primary hyperparathyroidism. It happens when one or more of the parathyroid glands is overactive. The most common cause of this overactivity is an adenoma — a growth in a parathyroid gland that is not cancer. It can also occur when the parathyroid glands are enlarged (hyperplasia). A cancerous tumor is a rare cause of primary hyperparathyroidism.

When the rise in blood calcium caused by primary hyperparathyroidism leads to symptoms, surgery is often needed to lower the amount of calcium in the body. If you develop primary hyperparathyroidism before age 50, your health care provider may suggest you have surgery even if you don't have any symptoms.

Secondary hyperparathyroidism

Another form of the disorder, called secondary hyperparathyroidism, sometimes requires surgery. Secondary hyperparathyroidism develops as a result of another medical condition, most often kidney disease. Parathyroid hormone is elevated as a response to low levels of calcium and vitamin D. This often can be treated without parathyroid surgery. If symptoms remain after treatment, then parathyroidectomy may be advised.

Risks

Parathyroidectomy is generally a safe procedure. But as with any surgery, it carries a risk of complications.

Potential problems that could happen after this surgery include:

• Infection

• A collection of blood (hematoma) under the skin of the neck that causes swelling and pressure

• Long-term low calcium levels due to removal of or damage to all four parathyroid glands

• Persistent or recurrent high calcium levels due to a parathyroid gland that could not be found during surgery or another parathyroid gland that becomes overactive after surgery

How you prepare

You may need to avoid eating and drinking for a certain period of time before surgery. Your health care provider will give you specific instructions. Before your surgery, ask a friend or family member to help you get home after the procedure.

Before the procedure

Imaging tests

One or both of these imaging tests may be used to locate the parathyroid gland or glands that are overactive:

• Sestamibi parathyroid scan. For this scan, you're given a shot of sestamibi into a vein. Sestamibi is a radioactive dye that is absorbed by overactive parathyroid glands. It can be found by a scanner that detects radioactivity. Computerized tomography (CT) scanning may be combined with the sestamibi scan to help make it easier to find problems with the parathyroid glands.

• Ultrasound. Ultrasound uses sound waves to create images of your parathyroid glands and surrounding tissue. A small device held against your skin (transducer) sends out high-pitched sound waves and records the sound wave echoes as they reflect off structures inside your body. A computer converts the echoes into images that can be seen on a screen. Ultrasound also can be used to identify thyroid nodules that may need treatment during a parathyroidectomy.

• 4D CT imaging. This is a type of CT scan that can be used to help find the location of an overactive parathyroid gland. It uses contrast dye to show the parathyroid gland.

During the procedure

In most cases, parathyroidectomy is done using general anesthesia. This means you won't be conscious during the procedure. General anesthesia allows the surgeon to use nerve monitoring during the procedure to assist in identifying the nerves that go to your voice box.

A blood test to measure parathyroid hormone typically is done during surgery. The results are used to help confirm that all of the overactive glands have been removed.

There are several surgical approaches that can be used for parathyroidectomy. Each of these surgeries involves an incision that often fades into a fine line.

• Minimally invasive surgery. This surgery typically is done when only one of the parathyroid glands is overactive. Using information from the imaging tests done before surgery, the surgeon locates and removes the overactive gland.

• Bilateral neck exploration. In this surgery, the surgeon looks at all of the parathyroid glands and removes the ones that are overactive. It may be done when a surgeon can't find a parathyroid gland on the side explored first. It also may be done if the imaging tests before surgery don't show an overactive parathyroid gland or show more than one overactive gland. Some medical conditions increase the risk for more than one overactive parathyroid gland, and a bilateral exploration may be done in those cases. Some surgeons may prefer to use this approach in all cases.

After the procedure

You may be able to leave the hospital the same day as the surgery. You might notice some discomfort at the incision site, or mild hoarseness and a sore throat from the anesthesia. A hoarse or weak voice from a nerve problem is very rare. If your voice is hoarse or weak after surgery, it doesn't necessarily mean there's permanent damage. These symptoms are often short term, but they can last several weeks or more. If hoarseness doesn't improve, you may need to have your vocal cords examined.

You'll be able to eat and drink as usual after surgery. Depending on the type of surgery you had, you may be able to go home the day of your procedure. In some cases, you may need to stay overnight in the hospital.

When you go home, you can usually return to your regular activities. Follow your health care provider's instructions on when you may return to vigorous activities, such as heavy lifting or strenuous sports.

After surgery, you may have a scar at the base of your neck. Your health care provider may advise using sunscreen to help keep the scar from being noticeable.

Results

Parathyroidectomy cures almost all cases of primary hyperparathyroidism and returns blood calcium levels to a healthy range. Symptoms caused by too much calcium in the blood may go away or greatly improve after this procedure.

After parathyroid glands are removed, the remaining parathyroid glands may take some time to work properly again. This, along with uptake of calcium into bones, can lead to low levels of calcium — a condition called hypocalcemia. You may have of numbness, tingling or cramping if your calcium level gets too low. This usually lasts only a few days or a few weeks after surgery. Your health care provider may advise that you take calcium after surgery to prevent low calcium. Typically, blood calcium eventually returns to a healthy level. Rarely, hypocalcemia may be permanent. If so, calcium supplements, and sometimes vitamin D, may be needed long term.

What is a Thryoidectomy?

Thyroidectomy is the surgical removal of all or part of your thyroid gland. Your thyroid is a butterfly-shaped gland located in the front of your neck. It makes hormones that control every part of your metabolism, from your heart rate to how quickly you burn calories.

Health care providers perform thyroidectomy to treat thyroid disorders. These include cancer, noncancerous enlargement of the thyroid (goitre) and overactive thyroid (hyperthyroidism).

How much of your thyroid gland is removed during thyroidectomy depends on the reason for the surgery. If you need only part of your thyroid removed (partial thyroidectomy), your thyroid may work normally after surgery. If you need your entire thyroid removed (total thyroidectomy), you need daily treatment with thyroid hormone to replace your thyroid's natural function.

Why is a Thyroidectomy performed?

Your doctor may recommend thyroidectomy if you have conditions such as:

• Thyroid cancer. Cancer is the most common reason for thyroidectomy. If you have thyroid cancer, removing most or all of your thyroid will likely be a treatment option.

• Noncancerous enlargement of the thyroid (goiter). Removing all or part of your thyroid gland may be an option for a large goiter. A large goiter may be uncomfortable or make it hard to breathe or swallow. A goiter may also be removed if it's causing your thyroid to be overactive.

• Overactive thyroid (hyperthyroidism). In hyperthyroidism, your thyroid gland produces too much of the hormone thyroxine. Thyroidectomy may be an option if you have problems with anti-thyroid drugs, or if you don't want radioactive iodine therapy. These are two other common treatments for hyperthyroidism.

• Suspicious thyroid nodules. Some thyroid nodules can't be identified as cancerous or noncancerous after testing a sample from a needle biopsy. If your nodules are at increased risk of being cancerous, you may be a candidate for thyroidectomy.

Risks of surgery

Thyroidectomy is generally a safe procedure. But as with any surgery, thyroidectomy carries a risk of complications.

Potential complications include:

• Bleeding. Sometimes bleeding can block your airway, making it hard to breathe.

• Infection.

• Low parathyroid hormone levels (hypoparathyroidism). Sometimes surgery damages the parathyroid glands, located behind your thyroid. The parathyroid glands regulate calcium levels in the blood. If blood calcium levels are too low, you may experience numbness, tingling or cramping.

• Permanent hoarse or weak voice due to nerve damage to the vocal cords.

How you prepare for surgery

Medications and food

If you have hyperthyroidism, your health care provider may prescribe medication such as iodine and potassium solution. Medication will help control your thyroid function and lower the risk of bleeding after surgery.

To avoid anesthesia complications, you may need to avoid eating and drinking for a certain amount of time before surgery. Your health care provider will give you specific instructions.

What you can expect

Before the procedure

Surgeons typically perform thyroidectomy using general anesthesia, so you won't be awake during the procedure. The anaesthetist gives you an anaesthetic medication as a gas — to breathe through a mask — or injects a liquid medication into a vein. After you're unconscious, a breathing tube will be placed in your trachea to assist breathing throughout the procedure.

The surgical team places several monitors on your body to check your heart rate, blood pressure and blood oxygen level throughout the procedure. These monitors include a blood pressure cuff on your arm and heart-monitor leads attached to your chest.

During the procedure

Once you're unconscious, the surgeon makes a cut (incision) low in the centre of your neck. It can often be placed in a skin crease where it will be hard to see after the incision heals. All or part of the thyroid gland is then removed, depending on the reason for the surgery.

If you're having thyroidectomy because of thyroid cancer, the surgeon may also examine and remove lymph nodes around your thyroid. In some patients, the surgeon uses special equipment to monitor irritation of vocal cords during the procedure to prevent permanent damage. Thyroidectomy usually takes 1 to 2 hours. It may take more or less time, depending on the extent of the surgery.

There are several approaches to thyroidectomy, including:

• Conventional thyroidectomy. This approach involves making an incision in the center of your neck to directly access your thyroid gland. The majority of people will likely be candidates for this procedure.

• Endoscopic thyroidectomy. This approach uses smaller incisions in the neck. Surgical instruments and a small video camera are inserted through the incisions. The camera guides your surgeon during the procedure.

After the procedure

After surgery, you're moved to a recovery room where health care providers monitor your recovery from the surgery and anesthesia.

Some people may need to have a drain placed under the incision in the neck. This drain is usually removed the day after surgery.

After thyroidectomy, some people may experience neck pain and a hoarse or weak voice. These symptoms typically last for only a short time. They may be due to irritation from the breathing tube inserted into the windpipe during surgery, or the result of nerve irritation caused by the procedure. In some cases, the hoarseness or weakness is caused by permanent damage to the vocal cords.

You'll be able to eat and drink as usual after surgery. Depending on the type of surgery you had, you may be able to go home the day of your procedure or stay overnight in the hospital.

When you go home, you can usually return to your regular activities. Wait at least 10 days to two weeks before doing anything strenuous, such as heavy lifting or high-impact sports.

It takes up to a year for the surgical scar to fade. Your doctor may recommend using sunscreen to make the scar less visible.

Results

The long-term effects of thyroidectomy depend on how much of the thyroid is removed.

Partial thyroidectomy

If only part of your thyroid is removed, the remaining portion typically takes over the function of the entire thyroid gland. So you might not need thyroid hormone therapy.

Complete thyroidectomy

If your entire thyroid is removed, your body can no longer make thyroid hormone. Without medication, you'll develop symptoms of underactive thyroid (hypothyroidism). These symptoms may include dry skin, fatigue and weight gain. You'll need to take a pill every day that contains the synthetic thyroid hormone levothyroxine.

This hormone replacement is identical to the hormone normally made by your thyroid gland and performs all of the same functions. Your health care provider will test your blood to know how much thyroid hormone replacement you need.