Details

Parathyroidectomy is a safe and effective procedure, and the risk of complications is very low. The most common complications are voice hoarseness and hypoparathyroidism.

Voice Hoarseness

• The nerves that supply the vocal cords are located at each side of the trachea (windpipe) beneath the thyroid gland.
• Injury to the nerves that control the vocal cords will cause hoarseness of the voice.
• In less than 1% of cases this voice hoarseness is permanent.
• About 25% of patients will experience some degree of voice dysfunction not related to nerve injury. This mild voice change is usually temporary and is caused by irritation from the breathing tube used during the operation and from operating around the voicebox. This mild voice dysfunction may take anywhere from a day or two up to a few months to resolve.

Hypoparathyroidism

Hyperparathyroidism is excessive activity of the hyperthyroid glands. There are three common forms of this condition:

• Sporadic primary hyperparathyroidism
• Secondary hyperparathyroidism
• Hyperparathyroidism related to Multiple Endocrine Neoplasm Syndrome

Of these three types, by far the most common is the first one, sporadic primary hyperparathyroidism (SHPT).

Sporadic Primary Hyperparathyroidism (SHPT)

Signs and symptoms of SHPT may be nonspecific, mild or severe.

The range of signs and symptoms include:

• Muscle weakness
• Bone and joint aches and pains
• Kidney stones
• Excessive urination
• Feeling thirsty more than normal
• Constipation
• Fragile bones that may easily fracture (osteoporosis)
• Depression
• Pancreatitis
• Stomach ulcers

The diagnosis of primary hyperparathyroidism is made by blood tests.  Calcium and parathyroid hormone (PTH) are measured.

The most common cause of SHPT is the development of a benign tumor (adenoma) involving one of the parathyroid glands. This overactive parathyroid gland is not cancerous; however, it induces high levels of calcium in the blood due to an overproduction of PTH that can cause a variety of health problems.

• In 95% of cases, there is a single adenoma.
• In 2% of cases, there will be 2 adenomas (double adenoma).
• Occasionally all four glands are overactive, a condition called parathyroid hyperplasia / multi-gland disease (3% of cases).

Cancer of the parathyroid glands is very rare (less than 1% of cases).

No imaging studies are necessary to make the diagnosis of HPT. However, these tests help the surgeon to preoperatively localize the offending gland or glands and allows him/her to perform a targeted, minimally invasive parathyroidectomy.  A combination of two imaging tests to locate the parathyroid gland or glands before parathyroidectomy can be performed:

• Ultrasound — a small device held on the skin of your neck
• Sestamibi scan — a mild, safe radioactive agent is injected into a vein, and an X-ray image of the head, neck, and chest is taken

Surgical removal of the abnormal parathyroid gland(s) or parathyroidectomy is the treatment for PHPT. A surgeon will remove one or more of the glands that are abnormal. If all four glands are abnormal, three glands and a portion of the fourth gland are removed, leaving some functioning parathyroid tissue in the neck (subtotal parathyroidectomy).

Preparing for Your Operation

You will be contacted by the pre-operative call center prior to your surgery to confirm the time and date of your surgery. If you do not hear from them by the business day before your surgery, please call them at 720-848-6070 between 2 and 4 p.m.
Do not eat or drink anything for 6 hours before the operation.
Shower or bathe as usual on the morning of the operation.

Medications

• Do not take aspirin, ibuprofen, or other non-steroidal anti-inflammatory drugs for 7 days before the operation.
• Stop herbal medications and supplements 2 weeks before surgery.
• Blood thinners such as Coumadin (warfarin), Pradaxa (Dabigatran), Xarelto (rivaroxaban), Eliquis (apixaban), Lovenox (enoxaparin),Fragmin (dalteparin), and Plavix (clopidogrel) need to be stopped a few days to a week prior to surgery. It is important to discuss with your surgeon exactly when these medications should be stopped.
• Stop ACE/ARBS medications 24 hours before surgery. These include any medication that ends with -pril or –sartan (e.g., Acupril,
• Losartan, Prinivil, Lisinopril)
• Do NOT stop inhalers and other lung medications.
• Do NOT stop beta blockers (metoprolol, atenolol, etc.)
• Discuss diabetes medications with your doctor or Pre-Procedure Services.
• Stop ADHD drugs one day before surgery.
• Stop cholesterol/lipid meds one day before surgery.
• Other medications such as antacid medications and medications for depression or anxiety are generally OK to take on day of surgery; discuss with your surgeon if you have questions.

When You Arrive

• When you arrive at the hospital, the first step will be registration. Then you will go to the pre-operative area, where a nurse will guide you through a series of safeguards and preparations for surgery.
• Next you will meet the surgical team, which includes anesthesia professionals, nursing staff, surgical residents, and your surgeon.
• You will be given general anesthesia, so you will be asleep during the procedure.
• The duration of the operation depends on the type and extent of the resection. Two to three hours is typical.
• Your surgeon will contact your family as soon as your operation is completed.

If you have questions before your surgery, please call 303-724-2724.

You will wake up in a recovery room.

• If you had a minimally invasive parathyroidectomy, you will be discharged home when your blood pressure, pulse, and breathing are normal.
• If you had a standard parathyroidectomy, you will stay in the hospital overnight. Your blood calcium level will be monitored.You should be able to go home the next day.

Pain will be controlled with oral pain medication.

Care at Home

• You can resume your normal diet as soon as you feel able. (You may have a little trouble swallowing.)
• You can shower 24 hours after your surgery, but do not swim or put your neck under water for 10 days.
• You may restart driving when you are off pain medications and you are able to move your neck to see over your shoulder with no trouble or pain.
• You can go back to work when you feel ready. Most patients request one to two weeks off from work.

Common Issues During Recovery

• You may feel tired for several days.
• You may have a mild to moderate sore throat.
• This discomfort is temporary and will get better with time.
• You may have a little trouble swallowing.
• You may have mild swelling and bruising in your neck and upper part of your chest.
• You may have low-grade fevers (less than 100o F) for a couple of days. You can take acetaminophen (Tylenol) to reduce the fever.
• For mild pain you may take acetaminophen (Tylenol).
  • Make sure you DO NOT take more than 3,000 mg of acetaminophen daily.
  • If pain is more severe or doesn’t get better with Tylenol, take the medication prescribed to you (e.g. ROXICET / PERCOCET / VICODIN).
• You may experience some constipation that is usually due to the pain medication.
• If you experience this problem, take a laxative such as colace or milk of magnesia twice a day while you are on the pain medication.
• Some patients experience hypocalcemia (low calcium) during their recovery period. See below for details.

Hypocalcemia (low calcium)

If you feel numbness of the face and/or tingling in your hands and feet, it’s a sign that your calcium level is too low. This is usually temporary and can be addressed by taking calcium pills.

The most common way to take calcium is as calcium citrate:

Calcium Citrate

• brand name: Citracal “Regular”
• dosage: 2 tablets (500 mg calcium and 400 units Vitamin D)
• frequency: 3 times a day for the first week, then decrease to twice a day

You may take an extra dose per day if you are still experiencing numbness and/or tingling.

An alternative is calcium carbonate, but some patients experience gastrointestinal side effects such as constipation with high doses.

Calcium Carbonate

• brand name: Caltrate 600·D3
• dosage: 1 tablet (600 mg calcium and 800 units Vitamin D)
• frequency: 3 times a day for the first week, then decrease to twice a day

You may take an extra dose per day if you are still experiencing numbness and/or tingling.

When to Contact Your Doctor

• If you have a fever greater than 101° F.
• If your pain is not controlled with the pain medication prescribed.
• If you experience symptoms of hypocalcemia (low calcium) that do not get better with the extra doses of calcium as described above,or if such symptoms worsen despite taking calcium.

After hours and on weekends you may contact the answering service at 303-724-2728.

Scar Management

Scarring is a part of every surgery and is very important to many patients for a variety of reasons: Scars may be painful, itchy or unsightly. Below is a list of common topical agents that are available over-the-counter for scarring.

Most incisions will heal to a thin, cosmetically acceptable scar without using any of the agents described below. However, if you would like to use a topical agent to improve healing and the cosmetic appearance of your scar, we recommend a silicone-based product. See below for additional details.

If you're short on time, you can skip to the summary.

Silicone

Silicones are synthetic polymers that can be a liquid, gel, or rubber.

Findings

Several studies illustrate that treatment of hypertrophic and keloid scars with silicone gel improves the appearance and bulk of the scars, especially in patients with burns. The superiority of one form of silicone gel dressing over another is not clear. Although both silicone gel sheeting and silicone gels improved scars, studies indicate no significant difference between the two forms.

Silicone dressings are believed to decrease scars via wound hydration, increased static charge, and modulation of growth factors.

Materials other than silicones (i.e., polyurethane) have shown to be equally effective in the treatment of hypertrophic scars. Both silicone and non-silicone gel dressings have been effective in reducing scar size, induration, and symptoms, but no significant differences have been noted between treatment with silicone and treatment with non-silicone gel dressings.

Bottom Line: There is good evidence showing the efficacy and safety of topical silicone for the treatment of hypertrophic and keloid scars. Silicone gel may improve the thickness, color, and texture of scars, especially thick ones. Although early treatment is ideal, silicone gel sheeting may still be beneficial for older scars.

Patients who wish to use silicone gel for scar management should apply it to the scar for 8 to 24 hours per day. It may take several months to see improvement.

Vitamin E

Vitamin E preparations are probably the most popular for use in improving the cosmetic appearance of scars.

Belief Basis

Early studies showed that vitamin E, applied topically, penetrates deep into the dermis and subcutaneous tissue, which is likely what led to the idea that vitamin E may improve wound healing when applied topically. When the skin is injured, free oxygen radicals are released in the inflammatory phase and may affect healing. In theory, Vitamin E could reduce free radicals by its antioxidant activity, thus enhancing wound healing.

Findings

Research on the effects of vitamin E on skin healing is sparse. Studies have shown that topically applied vitamin E provides no more effect than other emollient-type ointments, and hydration appears to be its only beneficial effect. Interestingly, topical vitamin E may actually cause more harm than good, possibly worsening a scar's appearance and causing contact dermatitis, contact urticaria, and erythema multiform-like reactions in some patients. A recent report from Widegrow has highlighted the skin irritation and reduced tensile strength caused by vitamin E. Use of vitamin E later on in the scar's maturity (4 to 6 weeks and later) may flatten the scar because of its hydrative capabilities, but it may result in a stretched and weakened scar because of its decreased strength effect on the scar; and if used too early, wound separation can occur.

Bottom Line: Although many patients believe vitamin E speeds wound healing and improves the look of a scar, current research evidence does not support this idea. In fact, studies report adverse effects with use of vitamin E.

We discourage patients from using topical vitamin E on healing wounds and scars.

Onion Extract

Another popular and heavily marketed over-the-counter scar treatment consists of onion extract in a topical gel, which has been marketed as a product to improve scar appearance and texture (Mederma, Merz Pharmaceuticals).

Theories

The mechanism of onion extract seems to reside in its antihistamine properties. The theory behind this is that a compound that blocks histamine release may decrease collagen production by fibro-blasts, resulting in reduced scar volume and normalization of the scar maturation process. The cosmetic result is a decrease in scar redness and hypertrophy.

Findings

Wounds treated with Mederma did show significantly better improvement of collagen organization. However, a prospective, double-blind study of Caucasian males demonstrated that the effects of topical onion extract on cosmetic appearance, erythema, and hypertrophy of scars in new surgical scars were equivalent to those of petroleum emollient.

Bottom Line: Products containing onion extract (i.e., Mederma) do not improve scar symptoms and have not shown any benefit over petroleum emollients. Applying this product to scars will probably not cause any harm, but will also probably not improve them.

Honey

Honey has been used as a dressing for wounds and burns for centuries.

Theories

Honey' effects on wound healing are theorized to be from its antibacterial activity in addition to its hydrating properties.

Findings

A review of 22 clinical trials involving more than 2,000 patients concluded that honey rapidly clears existing wound infections and protects against further infection, reduces swelling, minimizes scarring, removes infected and dead tissue, and speeds healing by stimulating new tissue growth.
Bottom Line: More well-designed, double-blind controlled trials in humans are needed, but preliminary studies are promising regarding honey and its wound-healing and scar-improvement properties.

Applying honey to a healing wound or existing scar has not been shown to be harmful and may speed healing and improve scar appearance.

What works? The bottom line

To summarize, silicone gel has the most data behind it as an efficacious topical, over-the-counter treatment option for scars, and is an option for patients who want something they can buy themselves. Also, there is probably not any harm, and possibly some benefit, to rubbing honey onto healing wounds and scars.

Further controlled studies involving human subjects are needed for topical, natural preparations for scars, so in the meantime, we recommend that patients not waste time or money on other “natural” products that claim to improve the look of scars.

Sample Products: Silicone-Based Scar Therapy

Useful Internet Resources

American Association of Endocrine Surgeons — Patient Education Site

American College of Surgeons — Surgical Patient Education