Complications
Hematomas can occur as a result of technical problems related to inadvertent dislodging of clips or sutures or rupture of previously ligated vessels. Postoperatively, patients should be observed in a monitored setting to assess for the development of neck hematoma.[2] The corrective action is prompt emergency hematoma evacuation and ligature placement. This problem typically resolves immediately on correction.[99]
Injury to the superior or recurrent laryngeal nerve may occur during surgical intervention. Damage to the superior laryngeal nerve may result in alteration in voice pitch. Injury to the recurrent laryngeal nerve results in hoarseness. Intraoperative vagal nerve monitoring is a patient safety technology used to help reduce this complication.[100] Recurrent and superior laryngeal nerve injury may be temporary or infrequently permanent. If resolution does not occur within 6 months, vocal cord medialization can be an effective treatment. This procedure involves an external approach through the thyroid cartilage and placement of alloplastic material to move the affected vocal fold to the midline.[101] Voice therapy may also be helpful.
Hypocalcemia may occur due to the phenomenon of hungry bone syndrome due to previously calcium-depleted bones benefiting from the reversal of the osteoclast activity and activation of osteoblasts. It may also be caused by devascularization or injury to other suppressed parathyroid glands during the surgical procedure. Alternatively, hypocalcemia may occur due to venous congestion of the parathyroid glands as a result of pressure in the wound from a hematoma. It is more common in vitamin-D deficient patients and in those who have received complete bilateral cervical exploration.[2] In patients who develop hypocalcemia, onset of symptoms most commonly occurs on postoperative day number 2 or 3; only patients with extreme elevations of calcium preoperatively occasionally present with symptoms on postoperative day 1. Patients almost never develop symptoms the day of surgery.[102] This problem typically resolves within hours if calcium supplements are given orally or within 1 hour if calcium supplements are given intravenously. In the event of temporary hypocalcemia, the corrective action will be oral calcium supplementation. Vitamin D should be given if the patient is deficient.[2] Some guidelines recommend considering short-term prophylaxis against hypocalcemia following parathyroidectomy with calcium and/or vitamin D supplementation, although the evidence in favor of this is weak.[2][103][104]
Parathyroid crisis, also known as hyperparathyroid crisis or parathyroid storm, is a rare complication in patients with PHPT. It is characterized by acute hypercalcemia and elevated parathyroid levels with end-organ involvement. Symptoms include dehydration, anorexia, vomiting, change in mental status, arrhythmias, and impaired renal function.[107] It must be treated promptly; medical management alone is likely to be ineffective at lowering the calcium level, but is used as a bridge to expedited parathyroid surgery, which is likely to be definitive.[108]
If persistent, noncurable, unresectable disease exists, protection of bone health with alendronate, estrogen, vitamin D, or denosumab should be considered, after consultation with an endocrinologist with special interest in bone health, although fracture data are unavailable.[1][63] Surgical treatment and antiresorptive therapies increase bone mineral density in mild PHPT similarly; the rate of bone loss is slow in untreated mild PHPT.[105]
Secondary to the calcium leaching from bones due to persistently high PTH, osteopenia and osteoporosis may result in bony fracture, especially of long bones. Treatment involves consultation with an orthopedic surgeon and appropriate casting and splinting.
Due to increased serum and urinary calcium levels, calcium may precipitate and form oxalate crystals and subsequent stones. Options involve treating the hypercalcemia following treatment options for hyperparathyroidism, and additionally considering lithotripsy or surgical options.[106] A urologist should be consulted.
Use of this content is subject to our disclaimer