What is hyperparathyroidism?
Hyperparathyroidism is a condition resulting from the excess production of parathyroid hormone. Most commonly (85%), a single parathyroid gland is enlarged, and produces excess parathyroid hormone (PTH), causing an abnormally high blood calcium level. Less often, two, three, or all four parathyroid glands may be involved. An abnormally high calcium level may be associated with kidney stones and damage, abdominal pain, loss of bone strength, bone and joint aches, non-specific fatigue, depression, memory loss, heartburn, sleep disorder, and perhaps accelerated cardiovascular disease. Because it is so slow in onset, patients may be unaware of any particular symptoms until they are directly questioned about them, and some report improvement in symptoms they were unaware of once they return for their post-operative visit.
In the past, many patients were not diagnosed until they were already suffering severe complications such as kidney stones, and severe bone disease. Today, most patients with hyperparathyroidism are diagnosed as a result of yearly routine blood work. If blood calcium is minimally elevated (less than 11 mg/100ml) and the patient has no symptoms, operation may not be necessary. However, if a patient is experiencing symptoms, bone thinning is detected, or blood calcium is more than 11mg/100ml, or if the patient is under 50 years old, the consensus amongst endocrinologists and surgeons is that surgery is appropriate.
Fortunately, almost all cases of hyperparathyroidism can be cured with a single operation. Most commonly, a single enlarged gland is removed. If more than one gland is enlarged, multiple glands may need to be removed. Enough parathyroid tissue will remain, however, to maintain normal function.
What types of scans are necessary before parathyroid surgery is scheduled?
Before surgery, we try to identify the side of the neck in which the overactive gland is situated. Both ultrasound technology and Sestamibi scanning may be used. While ultrasound technology is increasingly being performed by endocrinologists, if your endocrinologist doesn’t find the gland, I will ask you to have an additional ultrasound performed by a radiologist with whom I have been working with for years, who has immense experience in parathyroid and thyroid ultrasound. Since it is a noninvasive test, there is no risk in repeating the ultrasound. If the ultrasound and the Sestamibi scan fail to localize an abnormal gland, I may ask the patient to have a 4D CT scan. This is a newer test with excellent results. There is a small amount of radiation involved, but when performed by the radiologist I work with, it has been highly successful.
The other advantage of localization with ultrasound is that unrecognized thyroid nodules may be found, and if they are worrisome, a needle biopsy can be done to determine if the nodule needs to be removed at the same time as the parathyroid operation.
If localization shows an enlarged parathyroid gland, the procedure can be directed at that area, and the operation is likely to be on one side only. We are also able to use a rapid parathyroid hormone assay, which helps ensure the diseased gland has been removed.
However, even if the localizing tests do not show an abnormal parathyroid gland, an experienced parathyroid surgeon can still find the enlarged gland(s) in over 95% of cases during the first operation. In patients who have more than one gland involved, the localization tests can be less reliable, which makes choosing an experienced surgeon even more important. You can rest assured that I have performed several thousand parathyroid operations.
There is no difference in recovery when more than one gland is involved and the incision is not significantly larger.
Almost all parathyroid glands are found close to the thyroid gland in the neck. However, once in a while this is not the case, and parathyroid tissue may be located elsewhere, for example in the chest. Sometimes the Sestamibi scan or the 4D CT scan can show this prior to surgery, and guide the approach, which is still often via the neck.
How should I take my medications prior to surgery?
There are three medication categories which are of concern:
Anticoagulants: If you are on Coumadin or one of the newer anticoagulants such as Pradaxa, or anti platelet drugs such as Plavix, I almost always provide specific advice during the office visit. I often reach a decision in consultation with your cardiologist. If you are at all unclear about what you are supposed to do regarding anticoagulant meds please contact me at least a week prior to surgery.
Aspirin and Ibuprofen (Advil, Motrin) also have anti platelet effects: The rule used to be that you had to stop any of these drugs five days prior to surgery. There is however good evidence to show that low dose Aspirin can be continued. If you take low dose Aspirin as a general preventive measure, you can make your own decision about stopping or continuing. I do advise restricting Ibuprofen for 3-5 days prior to surgery unless you really need to take it.
Medications for hyperthyroidism: (PTU, Methimazole, or Metoprolol) If your surgery is to treat Grave’s disease, or you have an overactive goiter you must NOT stop the medications prior to surgery, and should even take them on the morning of surgery with a sip of water unless anesthesia instructs your otherwise during your preoperative assessment. Following operation you will discontinue all these medications and instead take thyroid hormone. You must have a prescription for thyroid hormone prior to leaving the hospital.
Diabetes medications: During your preoperative assessment you will receive instructions regarding your medications for diabetes.
To be clear, please contact me if you have any questions about any medications prior to surgery.
How can I prepare for my surgery?
Please do not take aspirin or any anti-inflammatory drugs including Advil or Motrin for at least five days prior to surgery. These drugs can interfere with platelet function, and may increase bleeding. If you accidentally take one of these drugs within five days of surgery, please let me know. If you have had a stent placed in your coronary arteries within the past 12 months, it may not be safe to stop your aspirin regimen, and we will need to discuss this with your cardiologist. Tylenol does not interfere with platelet function and is safe to take for headaches or minor pains before surgery.
Because general anesthesia will be administered for the operation, you will require an evaluation a few days before your surgery. Depending on your age and general health, this evaluation may be conducted by telephone, or you may need to be seen in the preoperative testing unit at the hospital. This decision will be made at the time we set up your operation. If you need to be seen, you will be given an appointment, time, and directions for the preoperative visit. Whether the evaluation takes place over the phone or in person, you will be asked many of the same questions that I asked in our first visit, particularly about medications and any past anesthetic history. During the preoperative evaluation, you will be told when to stop eating and drinking, and what medications to take prior to surgery. Please be sure that you understand these instructions and follow them. Otherwise, your surgery could be cancelled.
Please call your endocrinologist to let them know the date of your surgery and ask them when you should be seen for a postoperative visit.
How do I confirm the time of my surgery?
Make sure that we have a number to call in case the time of operation is changed with late notice. Call my office on the day before your surgery to confirm the time and place. If your operation is scheduled for a Monday, call the office on the preceding Friday between 9 am and 2 pm to confirm the time. Should you develop a cold, sore throat, fever, or other symptoms of a viral illness in the days before the scheduled operation, be sure to let the office know so that we can decide on the best course of action.
What can I expect when I arrive at the hospital?
You will first register at the reception desk, so that the staff is aware of your arrival before you proceed to the waiting area. After a brief wait, you will be taken to the preoperative holding area where you will be made ready for surgery. You will see nurses, anesthesiologists, my surgical residents, and me. You will be asked to sign the consent forms for surgery and anesthesia. I will mark your neck in an optimal place, so that once healed, the scar will be barely noticeable. When all of the necessary checks have been made, we will take you into the operating room. You will have received some sedation and you may not remember being moved. The team will help position you on the table, and then the anesthesiologist will gently send you off to sleep.
Who will perform my surgery?
I will perform your thyroid surgery with the help of an assistant, who is normally a surgical resident. In some cases, there will also be a medical student present in order to observe. While I am teaching the resident, I am primarily focused on conducting your surgery. In fact, when training residents, I must make sure that the surgery I perform is top notch. I am in total control of every step of your operation – have no concern.
Will I need a blood transfusion?
Patients sometimes wonder about the need for blood transfusion. You will lose minimal blood during surgery. Unless there is a special situation that I would have discussed with you beforehand, you can assume you will not need a blood transfusion. One of the risks of any surgery is postoperative bleeding. This is very rare. If bleeding is significant, you will need to go back to the operating room. This is very rare (less than 1%) and even in this case, we rarely need to give a blood transfusion.
What will happen during my surgery?
I will begin the operation by cleaning the skin with antiseptic and then arranging towels around the area. I will use the pen mark placed on the prep area as a guide in order to open the skin and expose the area on which I am operating. After gaining exposure, I will inspect the area and decide on the best approach and whether one or more glands need be removed.
The laryngeal nerves, which control the quality of your voice, are sometimes closely involved with the lump on your gland, and these nerves may become stretched during the operation. Your voice may sound a bit abnormal for a few days, weeks, or, in rare cases, months. You may sound slightly hoarse, or you may be unable to shout or sing high notes. You will, however, be able to make yourself understood without difficulty. The nerves are very sensitive and sometimes even trivial stretching will affect them. I use a nerve monitor to help protect your nerves, but despite every precaution, vocal change is one of the risks of thyroid surgery. Fortunately, permanent change is very unusual (less than 1%). The risk to the nerves is greater but still very small if you have had prior thyroid or parathyroid surgery. Under those conditions, I may use a nerve monitor to reduce any risk to your voice even further.
Once in a while, we will need to remove a portion of the thyroid gland in order to remove the enlarged parathyroid gland, including in cases in which the enlarged parathyroid can be embedded in the thyroid.
The final cosmetic result is very important. I plan the incision with this in mind, and close the skin as neatly as possible. I will not make the incision any longer than necessary to perform the resection safely and properly. I close the skin with sutures under the skin, and then apply steristrips or skin glue to cover the actual wound.
If there is a family member you would like me to call following surgery, please ensure that I have a phone number at which they will be easily available. They will not be able to see you for a couple of hours after the surgery.
What can I expect during recovery? Once you have awoken from the anesthetic, you will be taken to the recovery room, and observed for an hour or two until you are fully awake. You will not have any tubes down your throat or drains in your wound. You will only have an IV in your arm. I will see you in the recovery room and will tell you how your procedure went, but you are unlikely to remember this because anesthetic drugs impair memory. I will call or speak with your family or friends as soon as the operation is over. They will be able to see you a couple of hours after surgery.
Patients often ask how much pain to expect. While the response seems variable, most patients do not report a great deal of pain. In any case, I will give you a supply of pain medication.
Most patients can go home within aa few hours of their parathyroid surgery. I will delay your discharge if you live alone, or a great distance from the hospital. In addition, if the operation has taken longer than I expected, or starts late in the day, I may admit you to the hospital overnight. In some cases, the lingering effects of anesthesia can cause nausea, and discharge will be delayed. You will be under no pressure to leave the hospital if you are concerned.
At the time of discharge, you will be given a prescription for pain medication. All pain medication has a constipating effect. You may be able to avoid this by using a stool softener such as Colace or Metamucil. These are over-the-counter preparations, and you can use them in the event that you become constipated. They must be taken with a large amount of water.
When the overactive parathyroid gland is removed, your blood calcium level will drop, because the PTH is normal or low. We cannot predict whether the calcium drop will be small or large. The calcium drop generally becomes most marked at about 2-3 days following operation. If your calcium level drops quickly, you may experience some new symptoms. These include tingling around the lips, tongue, face, fingers, or toes. If the tingling is mild, please obtain TUMS or Oscal and take two every 2-3 hours while you are awake. If the tingling gets worse despite this, please call me, and I will ask you to have your blood calcium level checked. If your hands and feet become stiff, come to the ER at the Beth Israel Deaconess Medical Center or to your local hospital. Tell the ER staff that your calcium could be low following parathyroid surgery, and they will check the level of calcium in your blood and give you intravenous calcium if necessary.
How do I care for my wound?
You can shower and expose the wound to water within a day of your surgery. Soaking the incision in a tub is probably best delayed for about a week, unless I have closed your skin with waterproof skin glue. When you get out of the shower, pat the area dry because wiping will tend to remove the steristrips. There is no need to cover the steristrips and they will generally stay on for a week to 10 days, but this is variable. You can trim the ends with scissors as they begin to peel off, and then remove them entirely after 7-10 days if they are still in place. Sometimes, neck incisions swell after a few days. This is normal and will go down within a few weeks. It is also normal for the skin above and below the incision to be numb. This can last for several months.
In order to reduce discoloration of the scar it is a good idea to apply an ultraviolet barrier cream (SPF 20) to the scar when you are exposed to sunshine, for two years following operation. Vitamin E is thought to help minimize scarring and my plastic surgery colleagues are keen on Scaraway, a silicone preparation available at CVS or online. Maderma is another preparation you can use to treat the incision. I have no preference. Any of these preparations can be used once the steristrips are off.
How should I change my diet?
There is no need for any special diet, but in the days after your operation you may find soft foods easier to swallow.
How much energy will I have after surgery?
Post-operative fatigue is a concern for some patients. For lack of a better term, I call it the “post-operative poop-out syndrome”. Patients notice a particular lack of energy, mostly in the afternoon, for up to six weeks following operation. This is normal for some patients, and should resolve completely by six weeks.
Can I remain active after my surgery?
I suggest a common sense approach to activity following thyroid surgery. You can return to work as soon as you are comfortable enough. If, for example, you have a sedentary job, you may wish to go back after a week. I would avoid contact sports, or activities such as skiing, until a fall will be unlikely to impair healing (three to four weeks). You can swim as soon as the skin has healed (5-7 days). You can drive a car as soon as you are comfortable and not taking pain medications, but remember that residual neck discomfort may prevent you from turning your head quickly. Therefore, please do not drive until you can turn you head normally.
What should I do if I experience concerns immediately following surgery?
You will always have access to medical professionals in the event that you experience a problem upon arriving home from your surgery. Problems that may concern you are excess swelling, redness, and tingling that won’t go away. Be ready to take a picture of your incision if there is a concern. It’s often helpful for me to see how it looks and can save you a trip to the hospital or my office. If you have trouble reaching me, please visit the emergency room. A resident from my team is always on call.
What can I expect from my post-operative visit?
I generally see patients in the office for a post-operative visit at about four weeks following surgery. Please call and make an appointment. I do not need to see you earlier unless one of my residents or I asks you to make an earlier appointment. Additionally, please call your endocrinologist’s office and make an appointment before or after you have seen me, depending on their preference.
If you live a long way from my office and you have recovered well, and have no questions or concerns, you may not feel inclined to travel all the way in to have me look at the wound. In that case please just call my office and tell the staff you have no particular need for a postoperative visit and can do this on the phone. Whatever suits you best is fine with me.
If you have not heard from me about the pathology results within seven working days of surgery, please call the office.
Finally, if you have any questions prior to surgery, write them down before you forget them, and call the office, or preferably email me directly.
About Dr. Mowschenson, Thyroid and Parathyroid Surgeon – Boston, Massachusetts
Peter Mowschenson MD is board certified by the American Board of Surgery and has been has been on the faculty of Harvard Medical School for over 30 years. He practices at Beth Israel Deaconess Medical Center and St. Elizabeth’s Medical Center. His clinical interests include his specialties, thyroid and parathyroid surgeries. He is a member of the American Association of Endocrine Surgeons, the Boston Surgical Society, the Massachusetts Medical Society, and the New England Surgical Society. Dr. Mowschenson is renowned in the medical community for his commitment to his patients and his expertise when performing surgery using the latest technology and medical advancements. His research has been published in internationally respected, peer-reviewed medical journals, most recently including both Radiology and the The American Journal of Surgery. Dr. Mowschenson also lectures on thyroid and parathyroid surgery.