Essentials of parathyroid imaging

Parathyroid localization is an essential component in the surgical management of hyperparathyroidism (HPT). Using preoperative imaging improves localization and allows focused single-gland surgery in many cases of sporadic primary HPT. In this article, we describe the most commonly used types of parathyroid imaging and their role in the preoperative imaging of patients with HPT. Ultrasound is an excellent first-line test that provides high-resolution real-time images with minimal cost and time and no radiation exposure. It also allows evaluation of concomitant nodular thyroid disease but is limited by ectopic glands in the chest and is operator dependent. Nuclear imaging is effective in localizing enlarged parathyroid glands, including ectopic mediastinal glands, but is more expensive, is time consuming, involves radiation, may be less sensitive for small adenomas, and gives less anatomical detail unless paired with computed tomography. Parathyroid protocol multiphase scans are sensitive and less operator dependent but require more radiation.