Overview

The parathyroid glands: anatomy and function

The four parathyroid glands are small endocrine glands — each roughly the size of a grain of rice — located on the posterior surface of the thyroid gland in the neck. Their sole function is to regulate blood calcium levels through the secretion of parathyroid hormone (PTH). Calcium is essential to bone strength, muscle contraction, cardiac rhythm and nerve function.

When one or more parathyroid glands produce excess PTH autonomously, the condition is called primary hyperparathyroidism (PHPT). This leads to persistently elevated blood calcium (hypercalcaemia) and, over time, to complications affecting the bones, kidneys, cardiovascular system and neurological function.

Primary hyperparathyroidism is caused in 85% of cases by a single benign parathyroid adenoma, in approximately 15% by multigland hyperplasia or multiple adenomas, and in rare cases (< 1%) by parathyroid carcinoma.

Symptoms & indications

When is parathyroid surgery recommended?

Primary hyperparathyroidism can present in very different ways. Many patients are diagnosed incidentally on a routine blood test. Surgical indications are established according to SFE-AFCE-SFMN 2024 guidelines:

Symptomatic hypercalcaemia

Serum calcium significantly above the upper limit of normal, causing fatigue, muscle weakness, difficulty concentrating, mood disturbances, constipation, nausea or abdominal discomfort.

Renal involvement

Nephrolithiasis (kidney stones), nephrocalcinosis or reduced creatinine clearance (eGFR < 60 ml/min).

Bone disease

Osteoporosis (T-score ≤ −2.5 on DXA), vertebral fracture or cortical bone loss on bone density measurement.

Age under 50

Surgery may be recommended regardless of symptoms given the cumulative long-term risk of complications from untreated hypercalcaemia.

Patient preference

Surgery may be offered to any patient with confirmed PHPT who prefers definitive curative treatment over long-term surveillance. Parathyroidectomy is the only curative treatment for primary hyperparathyroidism.

Before surgery

Preoperative workup and gland localisation

Before any parathyroid operation, a complete biological and imaging workup is performed to confirm the diagnosis and localise the responsible gland(s).

Biochemical assessment

Blood & urine tests

Serum calcium and PTH — to confirm PHPT and exclude secondary causes
Vitamin D (25-OH) — deficiency must be corrected before surgery
24-hour urinary calcium and creatinine — to exclude familial hypocalciuric hypercalcaemia (FHH)
Phosphate, alkaline phosphatase, renal function

Imaging (only when surgery is planned)

Gland localisation

Cervical ultrasound — first-line imaging (~70–80% detection rate)
Parathyroid scintigraphy (MIBI) — first-line functional imaging
Choline PET-scan — also first-line; particularly sensitive for ectopic and multigland disease
4D CT scan or MRI — reserved for reoperative cases or complex anatomy

When two concordant imaging modalities confirm a single adenoma, focused (minimally invasive) parathyroidectomy can be performed with cure rates of 91.9–97.8% (SFE 2024, R1, Rank A+++). When imaging is negative or discordant, bilateral cervical exploration is required.

🔎

Online diagnostic decision-support tool: Paraclic (paraclic.fr) is a free tool designed to guide the diagnostic approach for suspected primary hyperparathyroidism — from initial blood test interpretation through to the surgical indication assessment. It provides a structured, step-by-step framework aligned with current SFE guidelines, for patients and referring clinicians alike.

Technique

How parathyroid surgery is performed

Parathyroidectomy is performed under general anaesthesia through a small transverse incision at the base of the neck. The procedure lasts between 45 minutes and 2 hours depending on the surgical approach.

Reference approach — 80–85% of cases

Focused parathyroidectomy

When preoperative imaging has confidently localised a single adenoma, the procedure targets only the responsible gland through a minimal incision. Typically performed as day surgery, with same-day discharge.

Complex or multigland disease

Bilateral cervical exploration

When imaging is negative, discordant or when multigland disease is suspected, all four parathyroid glands are systematically explored on both sides. Required in approximately 15–20% of cases.

Near-infrared autofluorescence

Fluobeam LX — Fluoptics®

Near-infrared light illuminates parathyroid tissue through its natural autofluorescence — no injection or contrast agent required. Identifies the diseased gland and confirms that healthy glands are intact and well vascularised before wound closure. Key tool for preserving parathyroid function.

Intraoperative PTH assay

ioPTH — Miami criterion

A blood sample taken 10 minutes after adenoma removal. If PTH drops by more than 50% from baseline and falls within the normal range, biochemical cure is confirmed before the patient leaves the operating room. Eliminates unnecessary further exploration when cure is established.

NIM — Intraoperative nerve monitoring is used in complex cases, reoperations and bilateral explorations to protect the recurrent laryngeal nerves, which run close to the parathyroid glands. Wound closure uses absorbable sutures and surgical glue — no external stitches.

Recovery

Recovery after parathyroid surgery

Recovery after parathyroid surgery is rapid, particularly following focused parathyroidectomy:

Day of surgery: eating and drinking resumed within hours; walking permitted from the evening
Day 1: discharged home — day surgery is standard for focused parathyroidectomy
Days 2–7: mild neck discomfort; driving possible from day 7
Week 2–3: return to sedentary and light professional activity; air travel possible from day 7
Week 3: return to sport and physical exercise

Blood calcium normalises in most patients within the first 24–48 hours after surgery. A blood test review is scheduled at 3 weeks to check calcium, PTH and vitamin D levels. A structured 1-year follow-up is recommended: biochemistry and bone density assessment (DXA) to confirm disease remission and evaluate bone recovery.

Safety profile

Risks of parathyroid surgery

Parathyroidectomy is a safe procedure when performed by an experienced endocrine surgeon. According to SFE 2024, permanent complication rates are 3 to 8 times lower in specialist high-volume centres than in low-volume units.

Transient hypocalcaemia

The most common complication, resulting from transient suppression of the remaining parathyroid glands. Managed with oral calcium and vitamin D supplementation; resolves spontaneously within days to weeks. Dr. Guian uses Fluobeam LX to identify and protect all healthy glands, significantly reducing this risk.

Common — transient

Voice changes

Temporary hoarseness due to recurrent laryngeal nerve irritation. Permanent vocal cord palsy is rare. NIM monitoring is used in complex and reoperative cases.

Permanent: < 1%

Persistent or recurrent disease

Occurs in 2.5–5% of cases at long-term follow-up. When it does occur, repeat imaging and discussion in a multidisciplinary specialist team are required before any decision on reoperation.

2.5–5% long-term

The surgeon

Dr. Gaël Guian — Endocrine Surgeon in Paris

Dr Gaël Guian
Endocrine surgeon

Dr. Gaël Guian is a surgeon exclusively specialised in thyroid and parathyroid surgery in Paris. He applies the full SFE-AFCE-SFMN 2024 consensus recommendations in his daily practice, with systematic use of Fluobeam LX autofluorescence and intraoperative PTH assay in every parathyroid procedure.

Holder of the Inter-University Diploma (D.I.U.) in endocrine surgery and accredited by the French Health Authority (HAS), Dr. Guian trained for four years in dedicated endocrine surgery units, including at Pitié-Salpêtrière Hospital under Prof. Fabrice Menegaux. He operates at Hôpital Privé des Peupliers, Paris 13th and consults at 69 Avenue Victor Hugo, Paris 16th.

✓ French Health Authority (HAS) Accredited

Learn more about Dr. Gaël Guian →

Frequently asked questions

Parathyroid surgery — frequently asked questions

What is the difference between the thyroid and the parathyroid glands?

The thyroid is a single butterfly-shaped gland at the front of the neck that regulates overall metabolism through thyroid hormones (T3 and T4). The four parathyroid glands are distinct, much smaller structures located on the back of the thyroid; they regulate blood calcium exclusively through PTH. They are two independent hormonal systems that happen to share the same anatomical neighbourhood — which is why their surgery is sometimes performed together.

Can primary hyperparathyroidism be treated without surgery?

Surgery is the only curative treatment. In patients who cannot undergo surgery or who prefer not to, active surveillance is possible — with annual blood tests and biennial bone density monitoring — combined where appropriate with medical therapy (cinacalcet to lower calcium, bisphosphonates to protect bone density). These treatments manage the consequences of the disease but do not remove its cause. The surgical option remains open and is reassessed at each follow-up consultation.

Is parathyroid surgery performed as day surgery?

In most cases, yes. Focused parathyroidectomy for a single adenoma is typically performed as day surgery with same-day discharge. Bilateral cervical exploration, required in more complex cases, may necessitate one overnight stay for postoperative calcium monitoring.

How will I know the surgery has worked?

Biochemical cure is confirmed intraoperatively using the PTH assay (ioPTH): if PTH drops by more than 50% from baseline and normalises within 10 minutes of removing the adenoma (Miami criterion), cure is established before the patient leaves the operating room. Blood calcium returns to normal within 24–48 hours and is checked at the 3-week review appointment.

Will I need medication after parathyroid surgery?

In most cases, no long-term medication is required after successful parathyroidectomy. A short course of oral calcium and vitamin D supplementation is commonly prescribed for the first few weeks to support the remaining parathyroid glands as they resume normal function. Once calcium levels have stabilised, supplementation is stopped and a simple annual blood test is all that is needed.

Book an appointment with Dr. Gaël Guian

Dr. Gaël Guian sees patients for surgical assessment of parathyroid conditions at his consultation office in Paris 16th (69 Avenue Victor Hugo, Métro Victor Hugo / Étoile). The consultation reviews your preoperative workup — calcium and PTH levels, imaging results — confirms the diagnosis and surgical indication, and provides a detailed explanation of the planned procedure.

French health insurance (Carte Vitale) accepted — Sector 2 with OPTAM-CO — Typical waiting time under 2 weeks

Book on Doctolib 01 45 02 18 18

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