Further Outpatient Care

Outpatient care for postparathyroidectomy patients involves continued monitoring of serum calcium levels (if low at discharge) and observation of wound healing. Furthermore, care should include treatment of accompanying tumors, such as in multiple endocrine neoplasia type 1 (MEN I).

Further Inpatient Care

Post-parathyroidectomy, the patient's serum calcium level must be closely monitored to determine if any evidence of transient postoperative hypocalcemia or hungry bone syndrome is present. Monitor wound healing and observe for damage to the recurrent laryngeal nerve.

Inpatient & Outpatient Medications

Cases of transient hypoparathyroidism post resection of an adenoma require treatment with calcium or calcium and calcitriol until calcemia has normalized, usually no longer than the first post-operative week. Calcium supplements may be required for a longer period in the presence of hungry bone syndrome.

Transfer

Transfer to another facility is necessary only if current facilities cannot provide the expertise of an endocrinologist, or experienced surgeon. The surgeon's experience is an important factor in the outcome of parathyroidectomies.

Complications

Surgical complications include recurrent laryngeal nerve injury, bleeding and infection. Complications of primary hyperparathyroidism include consequences of hypercalcemia, such as nephrolithiasis, dehydration, and cardiac arrhythmias, and complications due to end organ involvement such as renal failure and fractures.

Prognosis

For primary hyperparathyroidism, parathyroidectomy should be curative if the condition occurs in isolation. However, if it is associated with other tumors, prognosis would depend on the management of accompanying tumors.

Patient Education

Patients with primary hyperparathyroidism must understand the following:

Location and function of parathyroid gland and PTH
Effects of hypercalcemia on the body (eg, dehydration, neurological symptoms, arrhythmia, stones, bone demineralization, increased fracture risk)
Lack of success in managing primary hyperparathyroidism medically, need for surgical consultation, and resection of one or more parathyroid glands

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Media Gallery

Normal parathyroid glands as seen during a thyroidectomy. The large arrow points to the superior parathyroid. The thinner arrow points to the inferior parathyroid. The forceps points toward the recurrent laryngeal nerve. The patient's head is toward the right.

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Table 1. Causes of hyperparathyroidism

Table 1. Causes of hyperparathyroidism

Cause	Gene	OMIM
1. Neonate/Infant
Primary
- Familial hypocalciuric hypercalcemia	Heterozygous inactivating CASR mutations	145980
- Neonatal severe hyperparathyroidism	Homozygous inactivating CASR mutations	239200
Secondary
- Maternal hypoparathyroidism
- Maternal pseudohypoparathyroidism
- Maternal Vitamin D deficiency

2. Child/adolescent
Primary
- Sporadic adenomas
- Familial
* Familial hypocalciuric hypercalcemia (FHH)	CASR	145980
* Multiple Endocrine Neoplasia type 1 (MEN1)	MEN1	131100
* Multiple Endocrine Neoplasia type 2a	RET	171400
* Multiple Endocrine Neoplasia type 4	CDKN1B	610755
* Familial hyperparathyroidism jaw tumor syndrome (HRPT2)	CDC73	145001

- Autoantibodies to the CASR
Secondary
- Renal failure/post renal transplant
- Chronic hyperphosphatemia
- Vitamin D deficiency
* Nutritional
* Malabsorption
-Vitamin D dependent rickets type 1 VDDR1	CYP27B1	264700

- Vitamin D dependent rickets type 2 VDDR2	Vitamin D receptor	277440

-Other causes of hypocalcemia
Poor intake Drugs

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Author

Edna E Mancilla, MD Associate Professor of Clinical Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Attending Physician in Pediatric Endocrinology, The Children's Hospital of Philadelphia

Edna E Mancilla, MD is a member of the following medical societies: American Society for Bone and Mineral Research, Chilean Society of Endocrinology and Diabetes, Chilean Society of Osteology and Mineral Metabolism, Endocrine Society, Latin American Society of Pediatric Endocrinology, Pediatric Endocrine Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: IPSEN Biopharmaceuticals Inc<br/>Research support for: Clementia/Ipsen pharmaceuticals.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) Professor and Chair, First Department of Pediatrics, Athens University Medical School, Aghia Sophia Children's Hospital, Greece; UNESCO Chair on Adolescent Health Care, University of Athens, Greece

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) is a member of the following medical societies: American Academy of Pediatrics, American College of Physicians, American Pediatric Society, American Society for Clinical Investigation, Association of American Physicians, Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research, American College of Endocrinology

Disclosure: Nothing to disclose.

Chief Editor

Sasigarn A Bowden, MD Associate Professor of Pediatrics, Section of Pediatric Endocrinology, Metabolism and Diabetes, Department of Pediatrics, Ohio State University College of Medicine; Pediatric Endocrinologist, Associate Fellowship Program Director, Division of Endocrinology, Nationwide Children’s Hospital; Affiliate Faculty/Principal Investigator, Center for Clinical Translational Research, Research Institute at Nationwide Children’s Hospital

Sasigarn A Bowden, MD is a member of the following medical societies: American Society for Bone and Mineral Research, Central Ohio Pediatric Society, Endocrine Society, International Society for Pediatric and Adolescent Diabetes, Pediatric Endocrine Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Gordon L Klein, MD, MPH Clinical Professor of Orthopedic Surgery and Rehabilitation, University of Texas Medical Branch School of Medicine

Gordon L Klein, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American Society for Nutrition, American Gastroenterological Association, American Pediatric Society, American Society for Bone and Mineral Research, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Society for Pediatric Research

Disclosure: Nothing to disclose.

Phyllis W Speiser, MD Chief, Division of Pediatric Endocrinology, Steven and Alexandra Cohen Children's Medical Center of New York; Professor of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell

Phyllis W Speiser, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research

Disclosure: Nothing to disclose.