Surgery for Hyperparathyroidism

Hyperparathyroidism can lead to complications, including very high levels of calcium in the blood, osteoporosis, and kidney stones. If you have primary or tertiary hyperparathyroidism—in which one or more of the parathyroid glands contain an adenoma, a benign tumor—your doctor may recommend surgery to remove the overactive parathyroid gland.

Most commonly, only one parathyroid gland is overactive and needs to be removed. Because the four parathyroid glands are small and close to one another, identifying the abnormally functioning gland is essential before doctors perform surgery. 

At team of NYU Langone experts works closely together to identify which gland is overactive. In addition to your endocrinologist and surgeon, this team includes nuclear medicine specialists, radiologists, and sonographers, who perform tests that help in determining the best surgical treatment option.

Parathyroid Adenoma Imaging

A few tests are used to assist your doctors in determining which parathyroid gland requires removal. Identifying this gland before surgery helps to ensure that our surgeons can perform a minimally invasive procedure.

Sestamibi Scan

A sestamibi scan is a very common imaging test used to detect overactive parathyroid glands.

Shortly before the scan, you receive an intravenous (IV) injection with a very small amount of radioactive material called sestamibi. An overactive parathyroid gland absorbs this material more quickly than a normally functioning gland does.

The results of the scan show your surgeon which gland or glands are abnormally functioning and guide the surgeon in performing the surgery.

Ultrasound 

Your endocrinologist may order an ultrasound exam of the neck to help detect enlarged parathyroid glands.

An ultrasound test uses sound waves to produce images of the soft tissues in the body. In addition to helping to locate a parathyroid adenoma, ultrasound allows specialists to view images of your thyroid and surrounding tissues on a video monitor. 

Along with the sestamibi scan, an ultrasound can be very helpful in confirming the location of overactive parathyroid glands. An ultrasound exam can also reveal the presence of nodules on the thyroid, which is located in front of the parathyroid glands. Many people with parathyroid adenomas also have thyroid nodules. These nodules may require evaluation prior to parathyroid surgery.

Advanced Parathyroid Imaging 

If the overactive parathyroid can’t be located using sestamibi or ultrasound imaging, a four-dimensional CT scan, called 4-D, may be required. These images can be combined with additional sestamibi imaging, producing highly accurate maps of structures in the neck. These images reveal the tumor location, as well as tumor function. 

After sestamibi is administered, 4-D imaging is performed twice as you lie on a table for a few minutes each time. Images are taken when the sestamibi is first injected and again two hours later.

Focused Parathyroidectomy

Surgeons perform a focused parathyroidectomy when only one parathyroid gland is functioning abnormally and needs to be removed. During this procedure, which requires general anesthesia, the endocrine surgeon makes a small incision in the neck. Using information from the parathyroid adenoma imaging, the surgeon finds the affected parathyroid gland and removes it.

Surgeons take great care to avoid injury to other nearby glands and nerves. After the parathyroid gland is removed, the surgeon closes the incision with dissolvable sutures. 

During a focused parathyroidectomy, surgeons use a strategy called intraoperative parathyroid hormone monitoring. Your surgeon tests the parathyroid hormone levels in your blood before surgery and at intervals after removing the overactive gland to see if the hormone levels drop to the normal range. 

The parathyroid hormone levels are so sensitive that even within 10 minutes of removing a gland, parathyroid hormone levels in your blood can return to normal. Intraoperative parathyroid testing allows the surgeon to confirm that all overactive glands have been removed. 

Rarely, your surgeon may find that your parathyroid hormone levels don’t drop, even after removing the targeted parathyroid gland. If so, your surgeon may investigate which of the other parathyroid glands is causing the abnormally elevated parathyroid hormone levels. Based on the appearance of the gland, and with the help of intraoperative parathyroid hormone testing, additional glands that are functioning abnormally can be removed. 

The risks of parathyroid surgery are minimal, but can include bleeding and damage to the recurrent laryngeal nerve, which supports the muscles of the larynx, or voice box. NYU Langone surgeons are careful to use a laryngeal nerve monitor to identify and protect the recurrent laryngeal nerve.

Subtotal Parathyroidectomy

If you have a condition called parathyroid hyperplasia, in which multiple parathyroid glands are overactive, your doctor may perform a subtotal parathyroidectomy.

In this procedure, three and a half of the four parathyroid glands are removed. Generally, when all four glands are overactive, half of one gland is left in the body. It can produce an appropriate amount of parathyroid hormone for the body. 

During this procedure, which requires general anesthesia, your endocrine surgeon makes a small incision in your neck, then locates and removes the parathyroid glands one by one, leaving the correct amount of parathyroid tissue in the neck. Your surgeon uses intraoperative parathyroid hormone testing to make sure that levels fall into the correct range. 

As with a focused parathyroidectomy, surgeons take great care to avoid injury to other nearby glands and nerves. After the three and a half parathyroid glands are removed, the surgeon closes the incision in the neck with dissolvable sutures. 

Occasionally, too much of the parathyroid gland is removed, leaving you with hypoparathyroidism, or production of too little parathyroid hormone. If this occurs, your endocrinologist prescribes calcium and activated vitamin D supplements to help regulate the levels of calcium in your body and to compensate for the decreased production of parathyroid hormone. Activated vitamin D, also known as calcitriol, is available by prescription only and requires close supervision to avoid the risk of hypercalcemia, or high calcium levels.

For people who undergo subtotal parathyroidectomy for parathyroid hyperplasia, a portion of the removed parathyroid tissue may be frozen and stored, or cryopreserved. This cryopreserved tissue may later be reimplanted as a treatment, if needed, for postoperative hypoparathyroidism.

What to Expect After Surgery

Depending on your overall health and your doctor’s preference, you may be discharged the same day or the morning after surgery.

After surgery, you may have slight discomfort and swelling in your neck. Keeping your head elevated on a pillow and taking pain medication can make you more comfortable. A sore throat may occur, but this usually subsides within two days. If it persists, call your doctor. There are no restrictions on eating or drinking after surgery. 

Complications from parathyroid surgery are very rare, but they include infection, bleeding, and injury to adjacent parathyroid glands or the recurrent laryngeal nerve, which can cause hoarseness or the loss of your voice. If you experience any of these side effects after surgery, tell your doctor immediately.

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