Postoperative Instructions and Information for Parathyroidectomy

The Parathyroid Glands: Most people have 4 parathyroid glands that rest adjacent to the thyroid gland or in the gland itself. These are the size of a pea. Parathyroid glands help maintain a normal level of calcium in your body. Occasionally, one or more of the glands may secrete an excessive amount of Parathyroid Hormone (PTH). The excessive PTH can cause early bone resorption and kidney stones. The majority of the time, only one gland needs to be removed. Other times, 3-4 glands may be removed to achieve a lowering of the PTH level.

Sometimes gland tissue is transplanted into adjacent tissue in the neck (parathyroid auto transplantation) in an effort to maintain normal PTH levels in the future. This transplanted tissue may take a few months to work properly. Some patients may need to take a synthetic Vitamin D and calcium supplement after surgery. Your primary care doctor or endocrinologist may monitor calcium levels after surgery. A few percent of cases have either 5 glands or a gland in an unusual location. A second operation is sometimes needed to find these glands.

The Thyroid Gland: The thyroid gland is shaped like a bow tie; i.e. a larger lobe on each side of your windpipe (trachea) joined by a narrower isthmus. The thyroid gland commonly develops nodules that may resemble a parathyroid gland. The thyroid gland secretes thyroid hormone that is essential for the body. Many patients will need to take a thyroid hormone supplement after surgery. Your primary care doctor or Endocrinologist usually monitors thyroid hormone levels annually. Sometimes an abnormal parathyroid gland is inside of a thyroid lobe or otherwise difficult to separate from the lobe. In these cases, one or both thyroid lobes are removed during surgery.

The Recurrent Laryngeal Nerve: The nerve that controls much of the voicebox (larynx) runs adjacent to the thyroid gland. This nerve may not work well after surgery. This will lead to a hoarse, breathy voice and sometimes trouble swallowing. Mild hoarseness, after surgery is due to temporary swelling of the vocal cords from the breathing tube (endotracheal tube) placed by the anesthesiologist during the procedure. If both lobes are removed, both the left and right recurrent laryngeal nerves may not work, and the patient may have trouble breathing. This may require placing a breathing tube to through or below the voicebox (TRACHETOMY).

Parathyroidectomy: The removal of a parathyroid gland starts with a skin incision in the lower neck, above the patient’s breastbone. The abnormal gland is searched for carefully. This may require dissection of and around the recurrent laryngeal nerve. Lymph nodes and thyroid nodules may resemble parathyroid glands, and thus slow the dissection. Both sides of the neck may need to be explored. One or both of the lobes of the thyroid may be removed. The goal is to reduce the preoperative PTH level to < 50% of the preoperative value. Sometimes residual parathyroid tissue is transplanted into adjacent tissue or a distant site such as the forearm. A small drain tube is placed to exit the skin near the incision. The incision is sewn closed. The patient is then monitored for bleeding. The final pathology report may not be available until one week after surgery.

IF ONE LOBE OF THE THYROID WAS REMOVED AND THE PATHOLOGY SHOWS A MALIGNANCY, THEN ONE MAY NEED TO HAVE ANOTHER OPERATION TO REMOVE THE RESIDUAL THRYOID.

POST-OPERATIVE INSTRUCTIONS

Incision: Please keep the incision dry for 2-3 days, and then gently wash the incision with soap and water 2-3 times a day as needed. You may use Q-tips dipped in peroxide to remove any dried blood over the incision. After washing, please apply a thin film of an antibacterial ointment (e.g. Polysporin). Please avoid any activity that pulls across the incision such as shaving across the incision for at least 2 weeks. (The rest of the face may be shaved.) The staples and stitches will be removed 1-2 weeks after surgery.

Drain: Some patients are discharged with a thin drain tube and oval collecting reservoir called a grenade. Please empty the grenade and record the amount of fluid whenever the grenade looks half full or at least 2 times day. Discard the fluid in the sink or toilet; do not save it.

Head of Bed: Please elevate the head of your bed 30-45 degrees or sleep in a recliner at 30-45 degrees for the first 3-4 days to decrease swelling. The skin above the incision may look swollen after lying down for a few hours. Elevating the head is crucial when both sides of the neck have been dissected to avoid a “swollen, puffy neck”.

Activity: Please avoid any activity that raises your blood pressure for one week, e.g. heavy lifting, strenuous exercise, etc.

Diet: You may eat your regular diet after surgery. If the oral “pucker” muscles are weak, you may drool slightly when drinking or have trouble with very sticky foods like peanut butter. You may notice a slight increase in fluid from your incision while eating; this is normal and usually resolves by a few weeks.

Hypocalcaemia: The patient may experience a low calcium level after surgery. Symptoms could include: numbness (especially around the mouth) or abnormal muscle cramping. You may need to take calcium carbonate (e.g. Tums) or calcium gluconate along with a synthetic Vitamin D tablet after surgery. You may need to have calcium levels in your blood checked. Call our office or your endocrinologist if you have questions. Pain: Pain can be mild to moderate the first 24 – 48 hours, but usually declines thereafter. The sooner you reduce your narcotic medication use, the more rapid your recovery. As your pain lessens, try using extra-strength acetaminophen (Tylenol) instead of your narcotic medication.

Pain Management:

A realistic goal is to reduce the patient’s pain to a manageable level, and not to eliminate the pain. One cannot predict either a patient’s pain level or the necessary dose of pain medicine in all patients. One must approach each patient in a stepwise fashion for pain management. Specifically, please start at an intermediate dose of narcotic, and increase the dose if pain remains uncontrolled, or decrease the dose if the medications’ side effects are too severe. Close monitoring of the patient for side effects of each medication is essential.

Step 1: Acetaminophen (Tylenol) can decrease both pain and fever. The medication usually lasts for 3 – 4 hours. It is often combined with narcotics. It may be given orally as a liquid or pill or rectally (a suppository). Using the guidelines listed below, it would be difficult to take enough acetaminophen to reach toxic levels unless the patient has liver disease. One must add the acetaminophen already given to a patient previously in a narcotic combination (e.g. Tylenol with codeine or Hydrocodone with acetaminophen) when calculating the maximum next dose. Some patients who experience recurrent nausea or vomiting with narcotics do better using just plain acetaminophen for pain relief. Plain acetaminophen elixir is usually 160 mg per 5cc.

Step 2: Narcotics: Tylenol with codeine or Hydrocodone with acetaminophen (Lortab) are two commonly used narcotics. ALL narcotics may result in these side effects:

  • Nausea and vomiting.
  • Constipation.
  • Slowing of breathing rate and taking shallow breaths. Consequently, patients with sleep apnea need to avoid high doses of narcotics.
  • Slowed or altered mental status: sleepiness, mood shifts (including a wide spectrum from happy and carefree to anxious and upset).
  • Difficulty urinating.

Narcotic usage needs to be monitored much more closely than acetaminophen usage due to these potentially life-threatening side effects. General rules to follow include:

  • Never wake up a sleeping patient to give them narcotics.
  • Never combine narcotics with another sedating drug: e.g. alcohol, sleeping pills, Benadryl, or anti-anxiety pills such as Valium and Xanax.
  • Start with the lower dose prescribed, and take additional medication only if the pain is still not adequately controlled, 30 – 45 minutes after taking the first dose. For example, if the prescription reads “1-2 pills every 4 – 6 hours as needed for pain”, then start with one pill of pain medicine on the first dose. If the pain is not adequately controlled in 30- 45 minutes, then add one additional pain pill.

Every day, try to decrease the total amount of narcotic medication given, by:

  • Increasing the time between doses
  • Decreasing the number of pain pills used
  • Substituting plain acetaminophen for the narcotic.

REFILLS CANNOT BE TRANSFERRED BETWEEN PHARMACIES. PHYSICIANS CANNOT GIVE NARCOTIC PRESCRIPTIONS TO PEOPLE THAT THEY DO NOT KNOW.

  • Keep in mind that your surgeon is not on call 24 hours a day, seven days a week.
  • The doctor on call can be reached during office hours (9 AM to 4 PM, Monday through Friday), and by calling the office phone number at any time, 503-581-1567.

TO AVOID RUNNING OUT OF A NARCOTIC MEDICATION:

  • Please fill your narcotic prescriptions at a pharmacy that is open after hours and on weekends
  • Call our office by 2 pm the day BEFORE you will need a refill to give us time to process your request. Some family member will need to drive to our office to pick up the narcotic prescription (DEA rules). If you are taking narcotics, you cannot drive. You could be cited for “driving under the influence”.

Other Questions: For non-emergent questions, please call our office, 503-581-1567, between 9:00 am and 3:00 pm Monday through Friday. For emergent questions, call our office and our answering service will page the doctor on call. We have a doctor on call 7 days a week.

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