From the Guidelines
Complications of parathyroidectomy are a significant concern, with hypocalcemia and recurrent laryngeal nerve injury being the most common, and thus, patients should be closely monitored post-surgery, particularly when the procedure is performed by inexperienced surgeons.
Common Complications
- Hypocalcemia: occurring in up to 30% of patients temporarily and 1-3% permanently due to removal of overactive glands or damage to remaining parathyroid tissue, as reported in studies such as 1
- Recurrent laryngeal nerve injury: occurring in 1-2% of cases, causing hoarseness, voice changes, or difficulty swallowing, with long-term rates of 3% and 2.6% after total thyroidectomy, as seen in 1
- Bleeding complications: presenting as neck swelling and respiratory distress requiring immediate intervention, occurring in 1-2% of cases
- Infection rates: low, typically responding to antibiotics, occurring in 1-2% of cases
- Persistent hyperparathyroidism: resulting from incomplete removal of abnormal tissue or supernumerary glands, occurring in 2-5% of cases
Management and Prevention
Management involves calcium supplementation (calcium carbonate 1000-2000mg three times daily) and calcitriol (0.25-0.5mcg twice daily) for hypocalcemia, as well as close monitoring of calcium levels post-surgery, with frequent checks in the first 72 hours and regular follow-up for at least six months, as suggested by 1 and 1. The risk of complications increases with surgeon inexperience, reoperation, and extensive neck dissection, highlighting the importance of referral to high-volume centers for optimal outcomes, as noted in 1. It is crucial to prioritize the patient's quality of life, morbidity, and mortality when managing complications of parathyroidectomy, and thus, referral to high-volume centers and close monitoring post-surgery are essential.
From the Research
Complications of Parathyroidectomy
- The most common complications of parathyroid surgery include operative failure, recurrent laryngeal nerve paralysis, permanent hypoparathyroidism, hematoma, and error in diagnosis 2
- Metabolic derangements and injury to the recurrent laryngeal nerves are also significant complications of thyroid and parathyroid surgery 3
- Other complications include superior laryngeal nerve injury, infection, airway compromise, and bleeding 3
Recurrent Laryngeal Nerve Injury
- Recurrent laryngeal nerve (RLN) injury is a feared complication after thyroid and parathyroid surgery, inducing important postoperative morbidity 4
- The incidence of transient/permanent postoperative RLN injuries after thyroid and parathyroid surgery is significant, with 63 postoperative vocal cord pareses after thyroidectomy and 13 after parathyroidectomy 4
- Most patients with transient postoperative RLN injury recover normal vocal cord mobility within 6 months, with speech therapy being the most common performed treatment 4
Risk Factors and Outcomes
- Risk factors for permanent RLN injuries after thyroidectomy include previous thyroidectomy and intraoperative RLN injury 4
- The cure rate for primary hyperparathyroidism is high, with 98% for bilateral neck exploration (BNE) and 97% for minimally invasive parathyroidectomy (MIP) 5
- Hypocalcemia, laryngeal nerve injury, infection, and mortality are potential risks of parathyroidectomy, with MIP appearing to have a superior safety profile to BNE 5
Vocal Fold Paralysis and Paresis
- Vocal fold paralysis and paresis are complications of thyroid and parathyroid surgery, with paralysis being more severe and having a worse prognosis 6
- Vocal fold paresis patients regain normal vocal fold function significantly earlier than vocal fold paralysis patients and present with fewer symptoms 6