Otorhinolaryngology focuses on the ear, nose, and throat. Learn about the diagnosis and treatment of hearing loss, sinusitis, tonsillitis, and voice disorders.
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The treatment for primary hyperparathyroidism is surgical. Unlike thyroid disease or diabetes, there is no pill that can correct the broken mechanism of a parathyroid adenoma. While some medications exist to lower calcium levels temporarily, they do not stop the tumor from growing or damaging the bones. Therefore, parathyroidectomy is the standard of care.
The good news is that this surgery has evolved significantly. It used to require a large incision and a long hospital stay. Today, for most patients, it is a minimally invasive outpatient procedure. The surgeon’s goal is to remove the diseased tissue while protecting the voice and the calcium regulation system. This section delineates the various methods of performing this surgery and the options you may have.
This is the preferred method for most patients. It is used when the surgeon knows exactly which gland is bad before the operation starts, usually based on a positive scan (sestamibi or ultrasound). Because they have a “map,” they don’t need to explore the whole neck.
The surgeon makes a tiny incision, often just one inch long or less, directly over the spot where the tumor is located. They go straight in, separate the muscles, identify the tumor, and remove it. The entire operation might take only 20 to 30 minutes.
The benefits of MIP are significant. The incision is tiny and often hidden in a skin crease, making the scar barely visible once healed. There is less pain because less tissue is disturbed. Recovery is faster, with most patients going home a few hours after surgery. This approach heavily relies on accurate preoperative imaging to guide the surgeon to the correct location.
If the scans are negative (don’t show the tumor) or if the patient has more than one abnormal gland (hyperplasia), the surgeon performs a bilateral exploration. “Bilateral” means looking at both sides of the neck. “Exploration” means the surgeon looks at all four glands to see which ones are enlarged.
Even though this sounds bigger, the incision is usually only slightly larger than the minimally invasive one, perhaps 1.5 to 2 inches. The surgeon lifts the thyroid gland up to peek behind it. They inspect each of the four parathyroids. They remove any that look enlarged and leave the normal ones. This is a very safe and thorough operation. It is the “gold standard” because it allows the surgeon to be 100% sure that no bad glands are left behind.
This technique uses a radioactive probe in the operating room. On the morning of surgery, the patient receives a small injection of the sestamibi tracer (the same one used for scans). The tumor absorbs this radioactivity.
During surgery, the surgeon uses a handheld Geiger counter probe. The probe beeps loudly when it is pointed at the radioactive tumor. This helps guide the surgeon to the gland, even if it is hidden deep in the neck. After removing the gland, they examine the neck again to confirm that the radioactivity is gone. This technique is advantageous for finding ectopic glands—those that are not in the normal position but have migrated elsewhere in the neck.
One of the most significant advancements in this surgery is the ability to measure PTH levels right in the operating room. This is called “intraoperative PTH monitoring.”
Parathyroid hormone has a very short half-life—it disappears from the blood in minutes. Once the surgeon removes the suspected adenoma, the anesthesia team draws a blood sample from the patient while they are still asleep. They run a rapid test.
If the surgeon got the right gland, the PTH level in the blood will decline by more than 50% within 10 to 15 minutes. This confirms the cure immediately. If the level stays high, the surgeon knows there must be another harmful gland hiding somewhere, and they continue searching. This technology drastically reduces the failure rate of the surgery.
Parathyroidectomy is typically performed under general anesthesia. This means you are completely asleep and breathing through a tube or mask. General anesthesia is preferred because it keeps the patient perfectly still, which is vital when working near the delicate nerves of the voice box.
In some select cases, specifically with focused minimally invasive approaches, the surgery can be done under “local anesthesia with sedation.” The neck is numbed with injections, and the patient is given twilight medication to relax. They are awake but groggy and feel no pain. This procedure is an option for patients who cannot tolerate general anesthesia due to heart or lung problems, but most surgeons and patients prefer the control and comfort of general anesthesia.
The surgical strategy depends on what the surgeon finds. If it is a single adenoma (one harmful gland), they remove that one and leave the other three. This procedure cures the patient.
If four glands are enlarged due to hyperplasia, they can’t all be removed, or the patient will have no calcium and become very ill. Instead, they perform a “subtotal parathyroidectomy.” They remove three and a half glands. They leave a small piece of the most normal-looking gland behind. This small remnant has enough tissue to provide calcium for the whole body but reduces the total hormone output to normal levels. Occasionally, they implant this small piece in the muscle of the forearm. This way, if it grows back again in the future, a second surgery can be done on the arm instead of the neck.
Like any surgery, there are risks, though they are rare in experienced hands. The two main concerns are the recurrent laryngeal nerve and the remaining parathyroid glands.
The recurrent laryngeal nerve controls the vocal cords. It runs right next to the parathyroid glands. If it is stretched or damaged, the patient can have a hoarse or breathy voice. This condition is usually temporary but can be permanent. The other risk is that the remaining glands might go into shock and stop working temporarily (hypoparathyroidism), causing low calcium. This situation is treated with pills until they wake up. Bleeding is also a risk, but it is very uncommon. Choosing a high-volume surgeon who does this operation frequently is the best way to minimize these risks.
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A targeted minimally invasive surgery can take as little as 20 minutes. A full exploration usually takes about 45 minutes to an hour. You spend a few hours in recovery afterwards.
Yes, but it is usually tiny. Surgeons place the incision in a natural wrinkle or skin crease in the neck. Over a few months, it typically fades to a thin, barely visible line.
Most patients go home the same day (as outpatients). Some patients, particularly those with other health issues or who live alone, might stay overnight for observation.
This is rare. If the surgeon cannot find the gland after a thorough search, they will stop the operation to avoid damaging healthy tissue. You may need more specialized scans and a second operation later at a specialty center.
Most patients have no voice changes. There is a small risk of hoarseness if the nerve is irritated, but this usually resolves on its own in a few weeks
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