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Symptomatic

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  • Fractures (especially vertebral compression fractures).
  • Nephrolithiasis.
  • Severe neuromuscular weakness.
  • Easy fatigability.
  • Loss of stamina.
  • Sleep disturbance.
  • Depression.
  • Memory loss.
  • Pancreatitis.
  • History of an episode of life-threatening hypercalcemia.
  • Carcinoma.

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Asymptomatic

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  • Markedly elevated serum calcium (> 1.0 mg/dL above normal).
  • Markedly elevated 24-hour urinary calcium excretion (> 400 mg).
  • Abnormal serum creatinine.
  • Reduced bone mineral density (T-score < −2.5).
  • Age younger than 50 years.
  • Carcinoma.

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  • Pregnancy (first trimester).
  • Multiple comorbidities precluding safe intervention.
  • Idiopathic hypercalcemia.

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  • The patient should be supine with his or her legs slightly reclined and the head and shoulders raised (lawn chair position).
  • A towel roll or other small bump is placed beneath the shoulder blades to allow for neck extension and exposure.

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  • Although uncomplicated adenoma resection may often be performed as an outpatient procedure, patients who undergo the procedure as inpatients should be admitted for overnight observation and discharged the following morning.
  • In the early postoperative period, patients receive calcium carbonate, 1250 mg orally three times daily; or OsCal 500, 1 tablet orally three times daily (1 tablet OsCal 500 = 1 g CaCO3 = 400 mg elemental Ca or 20 mEq Ca), which can generally be reduced within 2 weeks.
  • Acetaminophen or ibuprofen, as needed, is prescribed for pain related to the procedure, and occasionally opioid agents are needed for a short time postoperatively.

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  • Neck hematoma.
    • May be self-limited if the airway is not compromised.
    • When the airway is compromised, there should be no hesitation in reopening the neck incision, including the strap musculature.
  • Hypoparathyroidism and hypocalcemia.
    • Typically present as perioral paresthesias, which may progress to more serious conditions, such as cardiac arrhythmias.
    • Treatment includes oral calcium carbonate, intravenous calcium gluconate, and possibly vitamin D.
  • Nerve injury: external branch of the superior laryngeal nerve.
    • Supplies motor innervation to the inferior constrictor muscles of the larynx.
    • Located near the superior pole vessels of the thyroid before entering the cricopharyngeal muscle at its superolateral aspect.
    • Damage will affect high-pitched singing or yelling.
  • Nerve injury: sympathetic chain/stellate ganglion.
    • Located posterior to the thyroid.
    • Damage will produce ipsilateral miosis, ptosis, and anhidrosis (Horner syndrome).
  • Nerve injury: recurrent laryngeal nerve.
    • Courses inferiorly to superiorly within the bilateral tracheoesophageal grooves and inserts at the inferior border of the cricopharyngeal muscles.
    • Damage causes ipsilateral paralysis to the vocal cord and may also affect the swallowing mechanism.
  • Thoracic duct injury, which may cause collection of chyle at the site of injury.
  • Tracheal injury.
  • Esophageal injury.
  • Persistent or recurrent hyperparathyroidism.

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