Chapter 2. Parathyroidectomy

Symptomatic

• 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.

Asymptomatic

• 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.

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

• 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.

• 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.

• 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.