Parathyroidectomy
Pathologies affecting the parathyroid glands are relatively common, affecting women preferentially (3 women for 1 man) after the age of 50. Often discovered by chance, or sought after in the follow-up of identified personal or family pathologies, surgery is in the vast majority of cases the reference treatment for these glands located at the base of the neck. As a professional specializing in surgery of the face and neck, the ENT surgeon is an indicated referent in the care of patients suffering from surgical parathyroid pathology.
Find out more about parathyroid gland surgery from Dr. Delagranda, ENT and cervico-facial surgeon in La Roche-sur-Yon, Vendée.
Parathyroid glands
The parathyroid glands are small endocrine glands, i.e. organs responsible for producing hormones released into the bloodstream.
As a reminder, hormones are chemical substances produced by glands, which act as messengers and influence the functioning of other organs throughout the body.
The hormone produced by the parathyroid glands is PTH (parathyroid hormone). It plays a central role in the regulation of calcium and phosphorus in the body. Under its action, calcium is drawn from wherever it is found: its absorption via the intestine is stimulated, its reabsorption in the urine is increased in the kidneys, and its mobilization from the bones is favored. Under its action, the calcium circulating in the blood (calcemia) is thus increased and can be distributed to the organs that need it, notably muscles for their contraction. To maintain the calcium balance required for the body to function properly (homeostasis), PTH secretion is finely regulated by a sensor located on the parathyroid glands, which is sensitive to variations in blood calcium levels. Phosphorus is much less problematic in its regulation, playing a role in energy transport and acidity maintenance. A very low level of phosphorus in the blood (hypophosphatemia) is merely a sign of severe malnutrition, and can be tolerated for a very long time (months). This is not the case for a low level of calcium (hypocalcemia), which can have serious repercussions within a few days (tetany, paresthesia, convulsions, heart rhythm disorders).
The parathyroid glands are small, oval-shaped formations, each measuring around 3 mm by 5 mm. As a rule, there are 4 of them: two upper and two lower. Located in the lower part of the neck, they lie deep down on either side of the trachea (the neck’s central respiratory axis), behind another well-known gland, the thyroid. In 1% of cases, the upper parathyroid glands are located either behind the esophagus, behind the pharynx or in the thyroid gland, in which case they are referred to as ectopic parathyroid glands.
Adjacent to the parathyroid glands, on either side of the trachea, runs the recurrent or inferior laryngeal nerve, responsible for innervation and movement of the vocal cords (1 nerve per side, for each vocal cord). In parathyroid surgery, these nerves must be carefully booked to avoid the risk of voice changes.
Hyperparathyroidism
In general, parathyroid pathologies are caused by increased secretion from one or more glands, leading to “hyperparathyroidism”.
There are three main types of hyperparathyroidism:
- Primary hyperparathyroidism, i.e. increased function of one or more parathyroid glands due to a pathology specific to one or more glands. Primary hyperparathyroidism therefore reflects inadequate functioning.
- Secondary hyperparathyroidism, i.e. an increase in parathyroid activity in response to stimulation: hypocalcemia, which has many causes. Secondary hyperparathyroidism therefore reflects adapted functioning.
- Tertiary hyperparathyroidism, which corresponds to the autonomization of one or more parathyroid glands following chronic hypocalcemic stimulation. Tertiary hyperparathyroidism thus corresponds to maladaptive functioning, following secondary hyperparathyroidism.
The consequences of hyperparathyroidism are those linked to its effects on calcium regulation (increased blood calcium through increased intestinal absorption, bone resorption and renal reabsorption). Hyperparathyroidism leads to hypercalcemia.
The symptoms of hypercalcemia are unspecific and wide-ranging: general (fatigue, weight loss, loss of appetite), digestive (nausea, abdominal pain, constipation), neurological (drowsiness, confusion, depression, headache, coma), renal (profuse urination, thirst, dehydration, renal lithiasis), cardiac (palpitations, rhythm disorders).
Chronic hypercalcemia is also responsible for calcium deposits, notably in the kidneys (renal colic, nephrocalcinosis), joints (articular chondrocalcinosis) and digestive system (biliary lithiasis, acute pancreatitis). Long-term damage can be serious and irreversible (chronic renal failure, chronic calcifying pancreatitis).
Finally, the stimulation of bone resorption to mobilize bone calcium through the inappropriate action of PTH is responsible for long-term arthroskeletal pathologies: osteopenia/osteoporosis, leading to fractures and bone pain.
Who is concerned by parathyroid surgery?
Surgery is the standard treatment for parathyroid pathologies.
Surgery is indicated even in the absence of symptoms, due to the long-term risks of hyperparathyroidism and hypercalcemia (see above).
It only concerns adults with primary or tertiary hyperparathyroidism and hypercalcemia (see above).
The symptoms of hypercalcemia are unspecific and wide-ranging: general (fatigue, weight loss, loss of appetite), digestive (nausea, abdominal pain, constipation), neurological (drowsiness, confusion, depression, headache, coma), renal (profuse urination, thirst, dehydration, renal lithiasis), cardiac (palpitations, rhythm disorders).
Under certain strict conditions, or in the event of contraindication to anesthesia, close monitoring with medical treatment may be proposed, in conjunction with the endocrinologist and attending physician.
The main parathyroid pathologies
Parathyroid pathologies requiring surgical coverage are those responsible for primary or tertiary hyperparathyroidism.
As a reminder, primary hyperparathyroidism corresponds to a maladaptive increase in the function of one or more parathyroid glands. Its annual incidence is estimated at 30 cases per 100,000. Tertiary hyperparathyroidism corresponds to the situation where one or more glands, after a phase of adapted stimulation, eventually become autonomous and function on their own, escaping all regulation: most often in chronic renal failure…
Parathyroid adenoma
Parathyroid adenoma is the most frequent pathology (85% of cases) responsible for primary hyperparathyroidism. It is a non-cancerous (benign) tumor of the parathyroid glands. It usually occurs in a single gland, but more rarely in 2 or 3.
A proliferation of PTH-producing parathyroid cells, this adenoma is responsible for an enlarged gland and increased PTH secretion, leading to hypercalcemia.
Sporadic, i.e. occurring at random, the discovery of a parathyroid adenoma is sometimes part of a genetic disease (NEM 1 and 2a) evoked by other symptoms or a family history.
A parathyroid adenoma may also be part of a form of tertiary hyperparathyroidism.
Diffuse parathyroid hyperplasia
Diffuse parathyroid hyperplasia is a non-cancerous condition characterized by enlargement of all 4 glands. It is found in 14% of cases of primary hyperparathyroidism.
Sporadic, i.e. occurring at random, diffuse parathyroid hyperplasia is sometimes found in the context of a genetic disease (NEM 1 and 2a) evoked by other symptoms or a family history.
Diffuse parathyroid hyperplasia may also be part of a form of tertiary hyperparathyroidism.
Parathyroid carcinoma
Parathyroid carcinoma is a cancerous tumor of a parathyroid gland found in less than 1% of primary hyperparathyroidism cases. It is a very rare cancer, accounting for less than 0.005% of all cancers, and is usually slow-growing.
Objectives of surgery
The aim of parathyroïd surgery is to restore proper blood calcium regulation, by removing one or more pathological parathyroid glands.
If cancer is suspected, the entire lesion can be analyzed to confirm its nature and adapt coverage.
Principles of the surgery
Surgery is usually performed under general anesthesia in the operating room, and usually requires 1 or 2 nights’ hospitalization. Under certain conditions, the procedure can also be performed on an outpatient basis. In some cases, local anesthesia and hypnosis can be used (ask your surgeon for details).
The procedure usually lasts between 1 and 2 hours, depending on the type of surgery (removal of one or more parathyroids) and the surgical procedure (conventional vs. minimally invasive).
A special intubation probe with a pressure sensor positioned opposite the vocal cords is used to monitor the recurrent nerve (nerve monitoring: a small electrical stimulation using a stylet confirms the presence of the nerve during dissection, and thus spares it as much as possible).
The surgeon makes a horizontal incision in the lower, central part of the neck, ideally in a natural fold of the skin to conceal the scar. The incision depends on the type of surgery and the size of the lesion to be removed. It generally measures 4 cm.
- For a parathyroid adenoma, the surgeon can perform either “conventional” surgery, i.e. remove the adenoma and then explore the other 3 parathyroid glands, so as not to miss another lesion, or “minimally invasive” surgery, targeting the adenoma identified on imaging tests, with no associated exploration of the other sites.
- In the case of diffuse hyperplasia, the surgeon explores and dissects the sites where the 4 glands are located, sometimes guided by the preoperative imaging work-up, to remove 3 of the 4 glands (3/4 parathyroidectomy) or, more classically, all 4 glands, preserving half of one (7/8 parathyroidectomy).
It is important to know that the lesion(s) removed by the surgeon are sometimes analyzed during the operation. Depending on the results of this “extemporaneous” analysis, the surgical procedure may be modified, and the operation lengthened or shortened.
At the end of the operation, 1 drain is often placed, a tube whose role is to aspirate secretions that accumulate in the operated area in the usual way. It is usually removed the same evening or the day after surgery, always before you leave clinic, depending on the amount of discharge and your surgeon’s judgment.
Complications of parathyroid surgery
Early complications
- Post-operative bleeding and hematoma: These complications are inherent to all surgery, and represent a low risk. In the event of minor bleeding or a small hematoma, maintaining the Redon drain and applying appropriate dressings may suffice to ensure good progress. In the exceptional case of heavy bleeding or a large haematoma, a further operation is required.
- Spontaneous neck pain and pain when swallowing: during surgery, the operating position requires you to put your neck in hyper-extension. In addition, the surgeon approaches the parathyroid glands after making an incision in the skin, pulling apart the muscles at the front of the neck that are involved in breathing, swallowing and phonation. This explains the frequent pain you may feel in the first few days, which is well relieved by painkillers.
- Voice disturbances: often minimal, and usually temporary, these are due to dissection of the parathyroid glands near the recurrent nerves (nerves that innervate the vocal cords and are responsible for their movement). Extremely rare in minimally invasive surgery, more frequent in bilateral surgery, modern cervical surgery tools help the surgeon to precisely control the location of the recurrent nerves, limiting accidental injury. Rarely, persistent voice disorders may require speech therapy. Exceptionally, in bilateral surgery, damage to both recurrent nerves may cause respiratory difficulties, leading to laryngeal surgery or tracheostomy.
- Hypocalcemia: Very common in the post-operative period, particularly in multi-gland surgery, hypocalcemia is generally transient. They usually manifest as tingling in the fingers, feet or around the mouth, cramps or transit disorders (constipation). In most cases, they simply require monitoring by blood sampling, and calcium and vitamin D supplementation by mouth for several days. This is particularly true in cases of osteoporosis (hungry bone syndrome). More rarely, these disorders are the cause of longer hospital stays for intravenous supplementation in the case of very serious disturbances. In exceptional cases, lifelong per os supplementation may be necessary.
Delayed complications
- Infection, evidenced by scar opening and/or pain and/or purulent discharge, is inherent to all surgical procedures. It may be encouraged by poor suture tolerance or poor local care. Antibiotic prescription is often necessary, and scarring results are often altered.
- Healing abnormalities: The healing process lasts several months, with scars evolving up to 1 or 2 years after surgery. Skin scars may become or remain inflammatory for several months, possibly warranting local corticosteroid injections. Very large, progressive hypertrophic scars (keloids) are occasional and may warrant further treatment.
For further information on adult parathyroidectomy, please consult the ENT College’s explanatory sheets:
Frequently asked questions about parathyroid surgery
Here is a selection of questions frequently asked by Dr Delagranda’s patients during consultations for parathyroid surgery in La Roche-sur-Yon.
Could be surgery unsuccessful ?
Sometimes, the pathological gland cannot be found by the surgeon, especially if it is ectopic (see above). This is a very rare situation, all the more so with the help of modern imaging techniques. The failure of surgery is in fact linked to the persistence of pathological glands not identified at the end of the preoperative work-up. New examinations and a new operation are then proposed.
I’ve been diagnosed with primary hyperparathyroidism on a blood test and want to have surgery. Do I need to undergo any other tests before going to see my surgeon?
Yes, for surgical coverage, at least one morphological examination is required to localize the lesion. Cervical ultrasound and/or sesta-MIBI scintigraphy are among the examinations required by the surgeon to propose an excision procedure.
I take anticoagulants or platelet anti-aggregants (such as Aspégic, Kardégic, Plavix, Préviscan, etc.). Do I need to stop them for the operation?
Except in special cases, you should stop taking your medication a few days before and after the operation to limit the risk of bleeding and hematoma. Your surgeon or anaesthetist will inform you of the deadlines to be respected, depending on your treatment and the procedure to be performed, during his or her preoperative consultation.
How do you know if your surgery has been a success?
Post-operatively, PTH levels are measured. Its normalization indicates the patient’s recovery. Calcemia will also return to normal.
How long do I need to protect my scar?
Once the sutures have been removed and your surgeon has checked that the scar has healed properly, you need to ensure systematic sun protection with sunscreen for a period of 1 year. Healing creams can also be recommended by your surgeon or pharmacy, to be applied daily for the first few months. The aim of these treatments is to ensure the best possible aesthetic result for your scar, which can change up to 1 year after surgery.
I was diagnosed with osteoporosis during a check-up. How will surgery affect my bones?
Once calcemia (blood calcium) and calciuria (calcium in urine) have been normalized, bone mass improves in 5 to 10% of osteoporotic patients within 2 years.
Fees and surgical coverage
Parathyroid surgery is covered by the French health insurance system. Contact your mutual insurance company to find out how much coverage there is for any extra fees.
Do you have a question? Need more information?
Dr Antoine Delagranda will be happy to answer any questions you may have about parathyroid surgery. Dr Delagranda is a specialist in ENT surgery at the Clinique Saint Charles in La Roche-sur-Yon in the Vendée.
ENT consultation for parathyroid surgery in Vendée
Dr Antoine Delagranda will be happy to answer any questions you may have about parathyroid surgery. Dr Delagranda is a specialist in ENT surgery at the Clinique Saint Charles in La Roche-sur-Yon in Vendée.