Introduction

Surgery can be scary for many people, especially when done on sensitive parts of our bodies like the neck. One such surgery is a parathyroidectomy, which may be a terrifying prospect. In actuality, it is a simple, non-invasive process that can be a cure to an otherwise nasty disease.

A parathyroidectomy is the removal of one or more of the parathyroid glands in the neck due to hyperparathyroidism.¹ The parathyroid glands are four, pea-sized structures nestled behind the thyroid gland in the neck; two near the top of the thyroid (superior parathyroid) and two near the bottom (inferior parathyroid). They play a major role in maintaining the optimal concentration of calcium in the body through the secretion of parathyroid hormone (PTH).² 

When diseases like primary or secondary hyperparathyroidism disrupt the delicate balance of calcium in the body, calcium levels increase and send the body into hypercalcaemia.¹ A parathyroidectomy is the only curative treatment available for these conditions and is recommended by healthcare practitioners.³ This article aims to discuss parathyroidectomy in detail, including the anatomy and function of the parathyroid glands and associated diseases, all to enlighten readers about this medical process.

Anatomy and function of parathyroid glands

Location of parathyroid glands

The parathyroid glands are four, pea-sized glands embedded inside the back of the thyroid gland in the neck.⁴ The location of these small structures on the thyroid can be split into four quadrants, two at the top right and left and two at the bottom right and left.

Role of parathyroid hormone (PTH)

The parathyroid gland produces and releases PTH to maintain a consistent amount of calcium in the body. PTH is released when the concentration of calcium in the blood is low, causing multiple organs in the body to help increase calcium levels. PTH causes the bones to release calcium, the kidneys to reduce calcium loss in urine, and the production of vitamin D to stop calcium loss in the intestines.⁴

The importance of calcium in the body

It is known that calcium is a key component in making our bones strong and healthy, but did you know calcium also plays a significant role in many of our bodily systems? Whilst 99% of the body's calcium is found in the bones, it also helps with muscle contraction, regulation of the heart’s rhythm, and transmission of nerve signals, and it also plays a role in blood clotting.⁵

Conditions requiring parathyroidectomy

Primary hyperparathyroidism

Parathyroidectomy becomes a medical necessity when certain conditions disrupt calcium levels in the body. Primary hyperparathyroidism (PHPT)), the most common disease associated with parathyroidectomy, stems from the overproduction of PTH, leading to hypercalcaemia.² PHPT is mainly caused by an adenoma (a non-cancerous growth) on one or more of the parathyroid glands, leading to uncontrolled production and release of PTH into the blood.² 

Due to increased routine testing, the vast majority of PHPT cases are diagnosed whilst the patient is still asymptomatic.² However, if left untreated it can cause kidney stones, the loss of bone mass (leading to bone pain, deformities, and fractures), and can impact the patient's mental health.² The best course of action for PHPT is parathyroidectomy, removing the affected glands and allowing the body to regulate calcium again.

Secondary hyperparathyroidism

Secondary hyperparathyroidism (SHPT) emerges due to conditions such as vitamin D deficiency and chronic kidney disease.⁶ Low vitamin D levels decrease the amount of calcium reabsorbed through the intestines, causing low calcium levels in the blood (hypocalcaemia). This subsequently leads to more PTH being released to increase calcium levels.⁶ Over a long period, this can lead to an increase in the size of the parathyroid glands, leading to hypercalcaemia.⁶

Due to the resulting hypercalcaemia, the symptoms of SHPT, if left untreated, are similar to those of PHPT. However, more non-surgical interventions are available for PHPT and surgery is usually offered when other interventions do not work. Parathyroidectomy will target some or all of the parathyroid glands and may include the autotransplantation of the glands to another part of the body.⁶

Preoperative assessment and preparation

Surgery can be a scary prospect for many people, with the preoperative phase leaving many patients stressed and confused. This article will now break down the process of parathyroidectomy, to shed light on the steps involved, starting with the preoperative assessments and preparing for surgery. Remember, it's always a good idea to have a thorough chat with your healthcare practitioner about any surgery you have.

Firstly, one to two weeks before the surgery, a series of tests including full blood work, a thorough review of the patient's medical history and a physical examination should be conducted to ensure the patient is ready for surgery.⁷

Imaging studies, including MRI and ultrasound of the neck, should be conducted to determine the exact location of the parathyroid glands and the specific glands to be removed.¹ These tests will allow the surgeon to perform the excision more precisely and make the surgery less invasive for the patient, making parathyroidectomy a safe surgery with few complications.¹ 

Surgical procedure

Parathyroidectomy is a minimally invasive, short surgery, and your healthcare practitioner should explain the procedure thoroughly beforehand. Generally, you will be asked not to eat or drink on the day of the surgery and to arrive at your appointment an hour to two early.⁷ The surgery is generally performed under general anaesthetic, however, recent reports have shown local anaesthesia to produce less postoperative pain, nausea, and vomiting.¹

Once the anaesthesia has taken hold, the surgeon will make a small incision, between 2.5 and 6 cm in length, into one of the folds of the neck above the collarbone. This ensures minimal scarring that is hidden in the neck's natural folds. The parathyroid gland is then revealed and carefully removed without injuring the surrounding tissue. The removed tissue will be tested to confirm it is the parathyroid gland. The blood PTH level will then be measured, with a successful surgery resulting in over a 50% drop in PTH levels to a normal amount.¹ 

In the case that this does not happen for the treatment of primary hyperparathyroidism, the surgeon will continue to look for additional adenomas to extract.¹ 

The surgery is completed by carefully stitching up the incision wound. Depending on the patient's age and medical history, they may need to stay in hospital overnight.⁷

Postoperative care and recovery

The recovery process after parathyroid surgery is generally quick and easy, and patients should make a full recovery in just a couple of weeks. Proper aftercare is paramount in healing after any surgery, and you should follow your healthcare practitioner’s advice and attend any follow-up appointments.

Rest is recommended for the first 24 hours after surgery, with the incision being covered by an adhesive, wound-closing strip.⁸ An ice pack can be applied to the neck for 24 hours, to help reduce swelling and numb any pain.⁸ The patient can shower as normal but should avoid soaking or scrubbing the incision.⁸ An antibiotic ointment will likely be prescribed to be applied after the bandage has been removed, around day four post-op.⁸ Sometimes the wound can bruise, swell or harden, but don't worry, these will typically go away after a few months. Patients should be able to return to their normal daily lives after a week or two of healing. After a parathyroidectomy, the remaining parathyroid glands don't work properly temporarily.¹ This occurs because the removed gland had been overproducing PTH to such an extent that the normal glands become used to being dormant. Therefore, blood calcium levels must be monitored to ensure they don't fall too much, resulting in hypocalcaemia. The symptoms of hypocalcaemia include headaches, cramps, and numbness of the extremities, and it is important that patients experiencing these symptoms contact their healthcare practitioner immediately. In the case of low calcium levels, the patient will likely be prescribed vitamin D and calcium.¹

Success rates and outcomes

Parathyroidectomy consistently demonstrates high efficacy in restoring normal calcium levels, alleviating symptoms, and enhancing the overall quality of life for patients with hyperparathyroidism. The success rates are notably high, with a significant improvement in symptoms such as fatigue, bone pain, and kidney issues. Quality of life metrics, including physical and mental well-being, show positive outcomes post-surgery.¹ While complications are rare, meticulous surgical techniques and postoperative care contribute to minimising risks. Monitoring for potential complications, such as hypocalcaemia, is essential for achieving successful outcomes in the majority of parathyroidectomy cases.

Complications

Like with any surgery, there is a risk of complications that can range from small to severe, however, it is worth noting that this surgery is considered very safe. If you have any concerns, please consult your healthcare practitioner.

• Haematoma: Reported in only 0.6% of surgeries haematoma is the pooling of blood under the skin which can result in compromised airways.⁸ Haematomas require urgent care and the reopening of the wound.¹
• Recurrent Laryngeal Nerve Injury: Damage to the recurrent laryngeal nerve can cause hoarseness, noisy breathing, and in severe cases, airway obstruction.¹ This may require the need for additional surgery, however, most patients recover fully after 6 months.¹
• Recurrent hyperparathyroidism: The recurrence of hyperparathyroidism can occur due to many reasons. Unrecognised issues with one or more of the remaining glands, the abnormal location of the problematic gland, or an inexperienced surgeon can all contribute to this complication.¹

Summary

In conclusion, parathyroidectomy is a surgical procedure crucial for addressing hyperparathyroidism, restoring calcium balance, and improving patients' quality of life. The surgery involves removing overactive parathyroid glands and resolving conditions like primary and secondary hyperparathyroidism. This surgery has a high success rate and is generally considered curative, providing lasting relief from associated symptoms and complications. Good postoperative care ensures a swift recovery, although there is a small risk of complications such as haematoma and nerve injury. It is key to always consult a healthcare practitioner for personalised advice and information.