Parathyroidectomy is performed most commonly in patients with primary hyperparathyroidism and those who are dialysis-dependent and have symptomatic secondary hyperparathyroidism. In patients who have hypercalcemia on dialysis or after renal transplantation (tertiary hyperparathyroidism), operation is also indicated. A physical examination, chest radiograph, and intact parathormone assay distinguish between primary hyperparathyroidism and the hypercalcemia of sarcoidosis, metastases, or a paraneoplastic syndrome. A 24-hour urinary calcium test is occasionally indicated to rule out familial hypocalciuric hypercalcemia. Currently, virtually all preoperative patients undergo localization studies such as cervical ultrasonography, computed tomography with intravenous contrast or radionuclide scanning after the intravenous injection of 99mtechnetium-labeled sestamibi in order to allow for shortened operations through limited incisions. A curative parathyroidectomy not only results in improvements in serum calcium but also improvements in bone density, neuropsychiatric symptoms, calciphylaxis, nephrocalcinosis, nephrolithiasis, and cardiovascular risk.
Preoperative therapy to lower extraordinarily elevated serum calcium levels in patients with parathyroid comas or suspected carcinomas should include saline infusions, furosemide, bisphosphonates and, occasionally, calcitonin. Parathyroidectomy is usually performed under general anesthesia through a low collar incision, although local anesthesia is appropriate for elderly and high-risk patients as well as those undergoing minimally radio-guided parathyroidectomy or image-guided focal exploration.