Common Questions about Parathyroid Surgery

Humans typically have 4 parathyroid glands that secrete a hormone (parathyroid hormone, or PTH) that helps control blood calcium levels. Several factors can lead to overactive parathyroid glands, called hyperthyroidism. The most common cause of hyperparathyroidism is a benign tumor on one of the parathyroid glands, which is NOT cancerous. Other causes can include overgrowth of all glands due to kidney disease, vitamin D deficiency, or genetic conditions. The diagnosis of hyperparathyroidism is made based on blood levels of calcium and PTH. Vitamin D levels are also important when considering a diagnosis of hyperparathyroidism and how it should be managed.
Unfortunately, symptoms from parathyroid disease can be vague, and are not necessarily related to the degree of calcium elevation or PTH hormone elevation. Some patients may notice symptoms even with normal calcium levels!

Common symptoms of hyperparathyroidism include:

  • Fatigue
  • Joint and muscle aches
  • Mood changes (such as loss of interest in usual activities or depression)
  • Memory and concentraion problems
  • Kidney stones and frequent urination
  • Abdominal cramps, ulcers, and changes in bowel habits
  • Bone loss (osteopenia or osteoporosis)
Because these symptoms can overlap with other medical problems (such as thyroid disease, low vitamin D, and other conditions), it can be hard to predict which symptoms are related; however, most patients with hyperparathyroidism feel noticeably better after surgery.
The National Institutes of Health (NIH) recommends parathyroid surgery for all patients with hyperparathyroidism and any of the following:
  • Age less than 50 years
  • Blood calcium >1.0 mg/dl above normal
  • Kidney stones or impaired kidney function
  • Osteoporosis
  • Your doctor will also take into account any symptoms that you are experiencing and other health factors to determine if and when parathyroid surgery is right for you.
Minimally invasive techniques allow surgeons to use smaller incisions and directed-dissection to perform surgery with less scarring and disruption of the tissues. For minimally invasive parathyroid surgery, incisions can be as small as 2 cm (just over 1/2 an inch!) and surgery can be performed as an outpatient procedure.
Undergoing special imaging studies prior to surgery, such as a high-resolution nuclear scan and/or ultrasound, can give your doctor additional information about the location and type of hyperparathyroidism. These studies may also determine your eligibility for a minimally invasive (or focused) surgery vs. the need for an open neck exploration. These studies may also help predict the likelihood of surgical success, and are generally considered cost-effective for your treatment. Additional technologies may be employed (based on availability and surgeon preference) to help plan surgery and improve surgical success, such as: 4D CT scan, intraoperative radiolocalization (gamma probe guidance), and/or intraoperative parathyroid hormone testing. Your surgeon can help decide if preoperative imaging studies or intraoperative testing will be helpful for you.
All surgeries - even minimally invasive surgeries - leave scars. We do everything we can to minimize the appearance of your scar. If you are prone to keloid scars (thick, raised scars), let your surgeon know in advance, as special techniques can be employed to reduce keloid formation.
After surgery, you will have a sore throat, and some swelling and discomfort at your incision in the lower neck. Most patients are able to manage this discomfort without narcotic pain medications.
  • You will be able to eat, drink, and talk immediately.
  • Driving is allowed as soon as patients have stopped narcotic pain medications, and feel able to turn their necks for safe driving (usually 2-3 days).
  • Most patients are fully recovered and back to work within 1 week.
  • Strenuous activity and heavy lifting are restricted for 1-2 weeks.
  • High dose calcium (3000-4000 IU/day) is recommended for 6 weeks after surgery for bone rebuilding.

Parathyroid surgery (like all surgery) carries the standard risks of anesthesia, a small risk of bleeding or infection, and the risk of other complications related to your underlying health problems; however, parathyroid surgery is typically considered safe, and complications rates are low when performed by an experienced surgeon. There are several additional complications that are specific to thyroid/parathyroid/neck surgery. The most common complication after parathyroid surgery is low calcuim. This can be caused by one or more factors. When one parathyroid is overactive, the other parathyroids may become underactive (atrophic), and may take some time to recover normal function. Additionally, many patients have "hungry bones" - bones that have been starved of calcium for years, and which rapidly absorb calcium once an overactive parathyroid is removed. Some patients require surgery on all 4 parathyroids, leaving them stunned. Low calcium from any of these causes is usually temporary. All patients are recommended to take extra calcium for 6 weeks after surgery for bone rebuilding. Some patients may require additional vitamin D as well.

Missed parathyroid/recurrent hyperparathyroidism. Parathyroid glands are small - typically the size of a grain of rice - and can be difficult to find, especially if they are only slightly enlarged or in an unusual location. Additionally, up to 15% of patients can have more than one abnormal parathyroid gland, which may not be apparent at the time of initial operation.

Voice changes can occur for many reasons after parathyroid surgery, but are rarely problematic or permanent. Swelling and inflammation in the throat, at the vocal cords, around the vocal cord nerves, and in the neck muscles can lead to some temporary hoarseness or voice tiring. Singers often notice subtle changes in their pitch and/or vibrato immediately after surgery, which resolves over time. Permanent voice weakness due to injury of a vocal cord nerve (recurrent laryngeal nerve) is rare - typically less than 1% for experienced surgeons. Additional procedures can be performed to strengthen a weak voice, but are rarely required. Injury or loss of both nerves requiring placement of a breathing tube (tracheostomy) is exceedingly rare. Many surgeons (including ours) use special monitoring devices to keep track of your recurrent nerves and vocal cord function during surgery.

Common Questions about Thyroid Surgery

Many thyroid nodules cannot be classified as "benign" or "malignant" based on the appearance of a needle biopsy alone. These "indeterminate" or "suspicious" nodules are generally recommended for surgical removal to allow for a diagnosis. Gene expression testing is a new technology that provides additional information about the proteins that are expressed by a nodule and its risk of cancer. Our practice uses Afirma® gene expression analysis to help guide decision-making for "indeterminate" nodules. If a nodule has a "benign" Afirma® profile, it is unlikely to be cancerous and can be safely observed without surgery. Nodules which have a "suspicious" gene expression profile are recommended for surgical removal. Afirma® testing can be performed on needle biopsy in our office - ask our staff if this testing may be useful for you.
Minimally invasive techniques allow surgeons to use smaller incisions and directed-dissection to perform surgery with less scarring and disruption of the tissues. For minimally invasive thyroid surgery, incisions can be as small as 3 cm (just over 1 inch) and can be outpatient procedures in certain cases.
After surgery, you will have a sore throat, some swelling, difficulty swallowing & discomfort at your incision in the lower neck.
  • You will be able to eat, drink, and talk immediately.
  • Driving is allowed as soon as patients have stopped narcotic pain medications, and feel able to turn their necks for safe driving (usually 4-5 days).
  • Most patients are fully recovered and back to work within 1 week.
  • Strenuous activity and heavy lifting are restricted for 1-2 weeks.

Thyroid surgery (like all surgery) carries the standard risks of anesthesia, a small risk of bleeding or infection, and the risk of other complications related to your underlying health problems; however, thyroid surgery is typically considered safe, and complications rates are low when performed by an experienced surgeon. There are several additional complications that are specific to thyroid/neck surgery.

The most common complication after thyroid surgery is low calcium, caused by disruption of the parathyroid (calcium) glands that sit behind the thyroid. This is usually temporary, and you may require extra calcium and/or a special form of vitamin D in the days or weeks after surgery. Depending on the extent of surgery and your anatomy, parathyroid glands may even be moved (autotransplanted) to another location (usually the muscle on the side of the neck) and can take additional time to recover.

Voice changes can occur for many reasons after thyroid surgery, but are rarely problematic or permanent. Swelling and inflammation in the throat, at the vocal cords, around the vocal cord nerves, and in the neck muscles can lead to some temporary hoarseness or voice tiring. Singers often notice subtle changes in their pitch and/or vibrato immediately after surgery, which resolves over time. Permanent voice weakness due to injury of a vocal cord nerve (recurrent laryngeal nerve) is rare - typically less than 1% for experienced surgeons. Additional procedures can be performed to strengthen a weak voice, but are rarely required. Injury or loss of both nerves requiring placement of a breathing tube (tracheostomy) is exceedingly rare. Many surgeons (including ours) use special monitoring tubes to keep track of your recurrent nerves and vocal cord function during surgery.

Whether or not you need hormones after surgery depends on the extent of your surgery and diagnosis. Most people can maintain adequate thyroid hormone levels with only half of the thyroid gland. If you have underlying thyroid problems (such as Hashimoto's disease or underactive thyroid), or have surgery for thyroid cancer, then you will likely need to take to take a hormone pill after surgery. Your doctor will be watching your hormone levels before and after surgery to determine your body's need for a supplemental hormone pill and the appropriate dose. Ask your doctor if a thyroid hormone pill is anticipated.
Robotic techniques are available to allow surgeons to perform thyroid surgery from hidden incisions in the armpit or behind the ears. This approach moves the incision so it is not visible on the front of the neck. Recovery has been similar to traditional thyroid surgery. Because robotic surgery has additional risks, takes longer than traditional open surgery, and is lacking adequate safety and outcomes research, the FDA suspended its approval of robotic thyroid surgery in October 2011. The FDA is re-investigating robotic thyroid surgery and may re-approve it in the future. Without the approval of the FDA and without the support of the manufacturer, we cannot offer or promote robotics at this time.
Most patients with thyroid cancer will be recommended to have their entire thyroid gland removed, along with a sampling of lymph nodes from around the thyroid (central neck dissection) in order to evaluate for spread and guide therapy. More extensive removal of lymph nodes may be required if spread to nodes is identified prior to surgery (usually found on exam or preoperative ultrasound). The need for additional treatment, such as Radioactive Iodine, is determined by the surgical findings and final pathology. Your care will be individualized based on the type of cancer, extent of cancer (stage of disease), and will also take into account other medical problems.
Generally, thyroid cancer is a slow-growing tumor, and takes many years to grow and spread. Most experts will recommend waiting until after delivery to proceed with treatment for thyroid cancer, as the risks of delaying treatment are thought to be minimal, and surgery and its side effects may pose additional problems for the pregnancy. Early induction of labor is also not typically recommended, and many physicians will also allow new mothers time to recover from childbirth and breastfeed (if they so choose) prior to proceeding with treatment.

Common Questions about Adrenal Surgery

The two adrenal glands are part of the body’s endocrine system and are located just above each kidney in the back of the upper abdomen. Although the adrenal glands are small, they produce several hormones that affect almost every system in the body. Hormones are substances carried through the bloodstream to many parts of the body where they regulate various body functions. Hormones produced by the adrenal glands include:
  • Aldosterone - regulates salt balance and blood pressure
  • Catecholamines, such as: epinephrine (adrenaline), norepiniphrine, and dopamine - affect heart rate and blood pressure
  • Cortisol - controls immune system, metabolism, salt balance and response to other hormones
  • Small amounts of androgens & estrogens (Sex hormones)
You need only about one-half of one adrenal gland for adequate hormone function. An adrenalectomy may be done if an adrenal gland contains a tumor or makes and secretes too much of one or more hormones. Adrenal gland tumors may be cancerous (malignant) or non-cancerous (benign); however, most adrenal tumors are benign.
A pheochromocytoma (or "pheo") is an adrenal tumor that secretes catecholamines (i.e. adrenaline). When bursts of catecholamines are secreted, patients often have symptomatic “spells” that last less than an hour. Common symptoms of a pheochromocytoma spell include:
  • High blood pressure
  • Palpitations or racing heart rate
  • Pounding headache
  • Anxiety/panic attacks
  • Flushing/sweats
  • Fatigue
Because a pheochromocytoma can secrete bursts of catecholamines (notably, epinephrine), surgery can be dangerous without special preparations. Your surgeon or endocrinologist will likely prescribe medications to block the effects of epinephrine and norepinephrine prior to surgery. You may be asked to stay in the hospital for several days, or to follow a special diet prior to surgery for additional preparations. Ask your surgeon about how to prepare and what side-effects to expect.
Cushing's Syndrome is when the body experiences excessive amounts of cortisol. Some common symptoms of excess cortisol include:
  • High blood pressure
  • Weight gain
  • Fatigue
  • Acne or facial hair
  • Rounding of the face and/or “Buffalo hump” (fat pad at back of neck
  • Straie (purplish stretch marks on the skin)
  • Elevated blood sugars
There are many potential causes of excessive cortisol, and extensive testing is required for diagnosis, as there is considerable variation in steroid production throughout the day. Adrenalectomy may be performed to remove one or both adrenal glands, depending on the cause of cortisol excess. After surgery most patients require additional steroids that are tapered over several months.
Primary hyperaldosteronism is excessive aldosterone production. Patients can experience severe high blood pressure that does not respond to typical medical therapy. Conn's syndrome is hyperaldosteronism from a benign adrenal tumor. Because microscopic adenomas and bilateral adrenal overgrowth can cause excessive aldosterone secretion, extensive work-up is required to identify the source (or sources) of aldosterone prior to planning treatment. Sometimes, treatment with medications that block aldosterone (e.g., Spironolactone) may be an alternative to surgery.
Most adrenal surgery is performed either laparoscopically or with the assistance of a surgical robot: several small incisions are made, the surgeon uses a small internal camera and instruments to remove the adrenal gland. Occasionally, open adrenal surgery is required, usually for large tumors, patients with extensive scar tissue from prior surgery, or suspected adrenal cancer. Your surgeon can discuss the approach that is best for you.

Adrenal surgery (like all surgery) carries some risk, and is best performed by an experienced surgeon. Typical risks include: risk of bleeding and infection, risk of injury to nearby organs, anesthesia complications, and additional risks related to your underlying hormonal imbalance and other health problems.

The most common risk is bleeding, which can be life-threatening and may require blood transfusion. For patients with pheochromocytomas, severe high blood pressure or abnormal heart rhythms can occur when the surgeon manipulates the adrenal gland during surgery (even with adequate preoperative preparations). Postsurgical risks associated with an adrenalectomy involve major hormone imbalances, caused by the underlying disease, the surgery, or both. These can include problems with wound healing, blood pressure fluctuations and other metabolic problems. If you have Cushing’s Syndrome, you can be at risk for adrenal insufficiency (low steroids) for months to years after surgery. An adrenal crisis can be severe and life-threatening. Your doctor can discuss with you signs and symptoms of low steroids and emergency treatment. Your doctor may also recommend a medic-alert bracelet. Discuss these possible risks with your surgeon.

Most patients require several days in the hospital to recover, followed by a several week recovery period at home. Overall, recovery from laparoscopic or robotic adrenal surgery is similar to recovery after laparoscopic gallbladder surgery.
  • Most patients resume a diet within a day or two of surgery.
  • Most patients require narcotic pain medications for several days to weeks after surgery.
  • Driving is allowed as soon as patients have stopped narcotic pain medications, and feel safe driving (usually 1-2 weeks).
  • Most patients are fully recovered and back to work within 2 weeks.
  • Strenuous activity and heavy lifting are restricted for 2-6 weeks, depending on the extent of surgery and underlying hormonal imbalance.
Some patients may require additional recovery time, especially if a more extensive surgery is required, or if they have Cushing's Syndrome.

Common Financial Questions

The cost of surgery includes the care your surgeon provides (usually 10% or less of the total amount) plus additional charges from other care providers (anesthesiologist, pathologist, surgical assistant, etc.), lab and radiology testing, hospital expenses, and nursing care.
A deductible is “the amount of expenses that must be paid out of pocket before an insurer will pay any expenses” (ref: Wikipedia).
A co-payment is a set amount that you are required to pay when you receive certain types of medical services. This may or may not be applied toward your deductible, depending on your insurance policy.
Co-insurance is “a percentage that the insurer pays after the insurance policy’s deductible is exceeded” (ref: Wikipedia). Depending on your plan, you may be responsible for additional costs beyond your deductible. Generally, most plans have an “out-of-pocket maximum” amount that you may be responsible for. Given the expense of surgery, most patients do end up being responsible for their full “out-of-pocket maximum”.
This depends on your insurance – call your insurance company or read through your policy to see what payments count towards your portion of the costs.

Other common questions

You can also read about common questions and answers about specific thyroid and parathyroid problems and treatments at Rose Thyroid Center

For more information, we recommend the following websites: