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<meta name="robots" content="INDEX,FOLLOW,NOARCHIVE" /><meta name="citation_inbook_title" content="StatPearls [Internet]" /><meta name="citation_title" content="Anatomy, Head and Neck, Parathyroid, Ectopic Glands" /><meta name="citation_publisher" content="StatPearls Publishing" /><meta name="citation_date" content="2023/07/17" /><meta name="citation_author" content="Bianca Georgakopoulos" /><meta name="citation_author" content="Yasir Al Khalili" /><meta name="citation_pmid" content="31082016" /><meta name="citation_fulltext_html_url" content="https://www.ncbi.nlm.nih.gov/books/NBK540972/" /><link rel="schema.DC" href="http://purl.org/DC/elements/1.0/" /><meta name="DC.Title" content="Anatomy, Head and Neck, Parathyroid, Ectopic Glands" /><meta name="DC.Type" content="Text" /><meta name="DC.Publisher" content="StatPearls Publishing" /><meta name="DC.Contributor" content="Bianca Georgakopoulos" /><meta name="DC.Contributor" content="Yasir Al Khalili" /><meta name="DC.Date" content="2023/07/17" /><meta name="DC.Identifier" content="https://www.ncbi.nlm.nih.gov/books/NBK540972/" /><meta name="description" content="Hyperparathyroidism is a condition mainly due to adenomas of the parathyroid that are overactive. Most cases of hyperparathyroidism go unnoticed because they are clinically silent. When symptomatic, the patient usually requires a referral to an otolaryngologist that will decide if surgery or medical intervention would better benefit the patient. If surgery is the option chosen, the patient will undergo imaging and a parathyroidectomy. Imaging is used to locate the parathyroid glands since these structures are notorious for being ectopically placed along a median line. If the clinical signs of hyperparathyroidism continue post-operatively, these serve as clues to the head and neck surgeon that there may be remaining tissue in the parathyroid, a parathyroid ectopically placed, or supernumerary parathyroids. Positive labs for continued primary hyperparathyroidism include hypercalcemia and high levels of PTH.[1] Symptoms of retained parathyroid tissue mirror symptoms of hypercalcemia: renal stones, osteoporosis, confusion, constipation, and weakness.[2]" /><meta name="og:title" content="Anatomy, Head and Neck, Parathyroid, Ectopic Glands" /><meta name="og:type" content="book" /><meta name="og:description" content="Hyperparathyroidism is a condition mainly due to adenomas of the parathyroid that are overactive. Most cases of hyperparathyroidism go unnoticed because they are clinically silent. When symptomatic, the patient usually requires a referral to an otolaryngologist that will decide if surgery or medical intervention would better benefit the patient. If surgery is the option chosen, the patient will undergo imaging and a parathyroidectomy. Imaging is used to locate the parathyroid glands since these structures are notorious for being ectopically placed along a median line. If the clinical signs of hyperparathyroidism continue post-operatively, these serve as clues to the head and neck surgeon that there may be remaining tissue in the parathyroid, a parathyroid ectopically placed, or supernumerary parathyroids. Positive labs for continued primary hyperparathyroidism include hypercalcemia and high levels of PTH.[1] Symptoms of retained parathyroid tissue mirror symptoms of hypercalcemia: renal stones, osteoporosis, confusion, constipation, and weakness.[2]" /><meta name="og:url" content="https://www.ncbi.nlm.nih.gov/books/NBK540972/" /><meta name="og:site_name" content="NCBI Bookshelf" /><meta name="og:image" content="https://www.ncbi.nlm.nih.gov/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-statpearls-lrg.png" /><meta name="twitter:card" content="summary" /><meta name="twitter:site" content="@ncbibooks" /><meta name="bk-non-canon-loc" content="/books/n/statpearls/article-20885/" /><link rel="canonical" href="https://www.ncbi.nlm.nih.gov/books/NBK540972/" /><link rel="stylesheet" href="/corehtml/pmc/css/figpopup.css" type="text/css" media="screen" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books.min.css" type="text/css" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books_print.min.css" type="text/css" /><style type="text/css">p a.figpopup{display:inline !important} .bk_tt {font-family: monospace} .first-line-outdent .bk_ref {display: inline} </style><script type="text/javascript" src="/corehtml/pmc/js/jquery.hoverIntent.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/common.min.js?_=3.18"> </script><script type="text/javascript">window.name="mainwindow";</script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/book-toc.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/books.min.js"> </script>
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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. </p></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK540972_"><span class="title" itemprop="name">Anatomy, Head and Neck, Parathyroid, Ectopic Glands</span></h1><p class="contrib-group"><h4>Authors</h4><span itemprop="author">Bianca Georgakopoulos</span>; <span itemprop="author">Yasir Al Khalili</span><sup>1</sup>.</p><h4>Affiliations</h4><div class="affiliation"><sup>1</sup> Virginia Commonwealth University</div><p class="small">Last Update: <span itemprop="dateModified">July 17, 2023</span>.</p></div><div class="body-content whole_rhythm" itemprop="text"><div id="article-20885.s1"><h2 id="_article-20885_s1_">Introduction</h2><p>Hyperparathyroidism is a condition mainly due to adenomas of the parathyroid that are overactive. Most cases of hyperparathyroidism go unnoticed because they are clinically silent. When symptomatic, the patient usually requires a referral to an otolaryngologist that will decide if surgery or medical intervention would better benefit the patient. If surgery is the option chosen, the patient will undergo imaging and a parathyroidectomy. Imaging is used to locate the parathyroid glands since these structures are notorious for being ectopically placed along a median line. If the clinical signs of hyperparathyroidism continue post-operatively, these serve as clues to the head and neck surgeon that there may be remaining tissue in the parathyroid, a parathyroid ectopically placed, or supernumerary parathyroids. Positive labs for continued primary hyperparathyroidism include hypercalcemia and high levels of PTH.<a class="bk_pop" href="#article-20885.r1">[1]</a> Symptoms of retained parathyroid tissue mirror symptoms of hypercalcemia: renal stones, osteoporosis, confusion, constipation, and weakness.<a class="bk_pop" href="#article-20885.r2">[2]</a></p></div><div id="article-20885.s2"><h2 id="_article-20885_s2_">Structure and Function</h2><p>The parathyroid glands are typically located posterior to the thyroid glands, but anterior relative to the rest of the neck. These glands primarily function as the regulators of calcium homeostasis. If there is normal anatomy, the inferior parathyroid glands are located at the lower poles of the thyroid gland, while the superior parathyroid glands are present near the upper poles.<a class="bk_pop" href="#article-20885.r3">[3]</a> Typically, a person has four parathyroid glands, but the number of glands can vary from one, up to as high as twelve glands in total. <a class="bk_pop" href="#article-20885.r1">[1]</a> The parathyroid glands are activated via G-protein coupled receptors (GPCRs) that are sensitive to surrounding parathyroid hormone. These GPCRs exist on bone and kidney cells.<a class="bk_pop" href="#article-20885.r4">[4]</a> The parathyroid hormone itself functions by increasing renal tubular calcium reabsorption, enhancing net bone resorption, as well as stimulation net intestinal calcium absorption by increasing Vitamin D because of activation of 1-alpha-hydroxylase in the proximal convoluted tubule.<a class="bk_pop" href="#article-20885.r5">[5]</a> Intermittent binding of PTH to its GPCR leads to bone formation, while constant binding leads to bone degradation.<a class="bk_pop" href="#article-20885.r4">[4]</a> Intermittent PTH activates osteoblast differentiation which enhances bone formation, resulting in net bone gain; continuous PTH leads to greater osteoclastogenesis.<a class="bk_pop" href="#article-20885.r6">[6]</a> PTH regulation is by ionized calcium, extracellular phosphate, and vitamin D. In contrast to other regulatory systems, the parathyroids are not under the direct influence of other glands and organs. Usually, in primary hyperparathyroidism, calcium levels remain elevated, while phosphate and Vitamin D levels are low (attempting to initiate negative feedback).<a class="bk_pop" href="#article-20885.r5">[5]</a></p></div><div id="article-20885.s3"><h2 id="_article-20885_s3_">Embryology</h2><p>The upper parathyroid glands descend from the fourth pharyngeal pouch within the thyroid, while the lower parathyroid glands travel with the thymus in the third pharyngeal pouch.<a class="bk_pop" href="#article-20885.r3">[3]</a> Due to the line of migration from the mandibular angle to the mediastinum, the ectopic glands can be located anywhere along this median line.<a class="bk_pop" href="#article-20885.r7">[7]</a></p></div><div id="article-20885.s4"><h2 id="_article-20885_s4_">Blood Supply and Lymphatics</h2><p>Inferior parathyroid adenomas are hypervascular and receive most of their blood supply from inferior thyroidal artery branches, while superior parathyroid adenomas receive their blood supply from the superior or inferior thyroidal artery branches. The ectopic parathyroid glands located in the mediastinum receive their vascular supply from the internal thoracic artery, specifically the thymic branch.<a class="bk_pop" href="#article-20885.r8">[8]</a></p></div><div id="article-20885.s5"><h2 id="_article-20885_s5_">Nerves</h2><p>Recurrent laryngeal nerve injuries are the most feared complication of parathyroid and thyroid operations due to the subsequent rise in postoperative morbidity. Some other symptoms of recurrent laryngeal nerve injury include vocal cord paresis or palsy, dyspnea, and deglutition.<a class="bk_pop" href="#article-20885.r9">[9]</a></p></div><div id="article-20885.s6"><h2 id="_article-20885_s6_">Muscles</h2><p>In some rare cases, ectopic parathyroid adenomas are present in the sternohyoid muscles.<a class="bk_pop" href="#article-20885.r10">[10]</a></p></div><div id="article-20885.s7"><h2 id="_article-20885_s7_">Physiologic Variants</h2><p>Another identified cause of primary hyperparathyroidism is an autosomal dominant condition known as multiple endocrine neoplasia type 1 (MEN1). The usual treatment of MEN1 in the context of primary hyperparathyroidism is surgical removal, but this is complicated when the parathyroid gland is ectopic. Ectopic parathyroid glands are more common in MEN1 patients than sporadically hyper-parathyroid patients.<a class="bk_pop" href="#article-20885.r11">[11]</a></p></div><div id="article-20885.s8"><h2 id="_article-20885_s8_">Surgical Considerations</h2><p>The upper parathyroid glands are found above the inferior thyroid artery, at the cervical level of the cricoid cartilage, and posterolaterally to the recurrent laryngeal nerve.<a class="bk_pop" href="#article-20885.r1">[1]</a> The upper parathyroid glands have to travel a shorter distance when compared to the lower parathyroid glands, so the upper parathyroid glands are generally not ectopic.<a class="bk_pop" href="#article-20885.r3">[3]</a> Regardless of this, there are many ectopic locations for the superior parathyroid glands, and they consist of the tracheoesophageal groove, posteromedial to the thyroid in the paraesophageal area, within the carotid sheath, within the thyroid gland itself, and in the mediastinum (anywhere from superficial to deep).<a class="bk_pop" href="#article-20885.r1">[1]</a> Typically, the inferior parathyroid glands are located below the inferior thyroid artery and anteromedially to the recurrent laryngeal nerve. Some usual ectopic locations for the inferior parathyroid glands include: within the thymus, the perithymic fac, the thyrothymic ligament, as well as within the carotid sheath, the thyroid glands themselves, and the anterior mediastinal glands.<a class="bk_pop" href="#article-20885.r1">[1]</a> The most common ectopic locations for the parathyroid are within the mediastinum, the thymus, and the thyroid gland. The rarest locations for ectopic parathyroid glands include within the vagus nerve or pharynx, and behind the esophagus.<a class="bk_pop" href="#article-20885.r10">[10]</a></p></div><div id="article-20885.s9"><h2 id="_article-20885_s9_">Clinical Significance</h2><p>Today, the majority of ectopic parathyroid glands are relatively silent without clinical manifestations. Because of this, surgery is not usually a recommendation unless the patient has symptoms. Guidelines for surgery include adjusted calcium over 0.25 mmol/L above the reference range, urine calcium greater than 10 mmol/ 24 hours, more than 30% reduction in creatinine clearance, less than -2.5 bone density T-score, and being less than 50 years old. Active ectopic parathyroid gland complications include namely hypercalcemia, which results in an increased fracture rate (more commonly in females), kidney stone disease, hypertension, cardiac valve calcification, and neurological symptoms (such as weakness, anxiety, and depression). For those patients that do not meet surgery guidelines, medications can be used and include hormone replacement therapy (specifically in post-menopausal women to decrease fracture rates) and calcimimetics that inhibit the release of PTH by binding to calcium receptors and dominating the negative feedback loop.<a class="bk_pop" href="#article-20885.r2">[2]</a></p></div><div id="article-20885.s10"><h2 id="_article-20885_s10_">Other Issues</h2><p>Usual imaging for parathyroid glands includes ultrasound and CT. Ectopic parathyroid glands are not readily visible with ultrasound, so technetium-sestamibi CT scanning may be a diagnostic option which has high sensitivity and specificity for parathyroid adenomas. <a class="bk_pop" href="#article-20885.r2">[2]</a> After removal, parathyroid glands are taken to pathology to determine malignancy status. Because the regulation of calcium is vital, many times, surgeons will autoimplant a parathyroid gland within the forearm of a patient. By doing this, the gland's functionality remains the same with a lower incidence of malignancy and hyperparathyroidism because of close monitoring by the physician and patient.<a class="bk_pop" href="#article-20885.r10">[10]</a></p><p>Ectopic parathyroid management requires close collaboration with an interdisciplinary team that includes the family physician, specialists, nursing staff, and pharmacists; this interprofessional team approach best leads to optimal patient management and clinical results. [Level V]</p></div><div id="article-20885.s11"><h2 id="_article-20885_s11_">Review Questions</h2><ul><li class="half_rhythm"><div>
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</div></li></ul></div><div class="floats-group" id="article-20885.s12"></div><div class="floats-group" id="article-20885.s13"></div><div id="article-20885.s14"><h2 id="_article-20885_s14_">References</h2><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="article-20885.r1">Caron NR, Sturgeon C, Clark OH. Persistent and recurrent hyperparathyroidism. <span><span class="ref-journal">Curr Treat Options Oncol. </span>2004 Aug;<span class="ref-vol">5</span>(4):335-45.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/15233910" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15233910</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="article-20885.r2">Fraser WD. Hyperparathyroidism. <span><span class="ref-journal">Lancet. </span>2009 Jul 11;<span class="ref-vol">374</span>(9684):145-58.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/19595349" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19595349</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="article-20885.r3">Taterra D, Wong LM, Vikse J, Sanna B, Pękala P, Walocha J, Cirocchi R, Tomaszewski K, Henry BM. The prevalence and anatomy of parathyroid glands: a meta-analysis with implications for parathyroid surgery. <span><span class="ref-journal">Langenbecks Arch Surg. </span>2019 Feb;<span class="ref-vol">404</span>(1):63-70.</span> [<a href="/pmc/articles/PMC6394670/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6394670</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30762091" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30762091</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="article-20885.r4">Culhane KJ, Belina ME, Sims JN, Cai Y, Liu Y, Wang PSP, Yan ECY. Parathyroid Hormone Senses Extracellular Calcium To Modulate Endocrine Signaling upon Binding to the Family B GPCR Parathyroid Hormone 1 Receptor. <span><span class="ref-journal">ACS Chem Biol. </span>2018 Aug 17;<span class="ref-vol">13</span>(8):2347-2358.</span> [<a href="/pmc/articles/PMC10640708/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC10640708</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/29952553" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29952553</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="article-20885.r5">Schappacher-Tilp G, Cherif A, Fuertinger DH, Bushinsky D, Kotanko P. A mathematical model of parathyroid gland biology. <span><span class="ref-journal">Physiol Rep. </span>2019 Apr;<span class="ref-vol">7</span>(7):e14045.</span> [<a href="/pmc/articles/PMC6440916/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6440916</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30927339" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30927339</span></a>]</div></dd><dt>6.</dt><dd><div class="bk_ref" id="article-20885.r6">Choi H, Magyar CE, Nervina JM, Tetradis S. Different duration of parathyroid hormone exposure distinctively regulates primary response genes Nurr1 and RANKL in osteoblasts. <span><span class="ref-journal">PLoS One. </span>2018;<span class="ref-vol">13</span>(12):e0208514.</span> [<a href="/pmc/articles/PMC6303058/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6303058</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30576321" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30576321</span></a>]</div></dd><dt>7.</dt><dd><div class="bk_ref" id="article-20885.r7">Patrinos A, Zarokosta M, Piperos T, Chrysikos D, Kakaviatos D, Theodoropoulos P, Kalles V, Tsiaoussis J, Noussios G, Mariolis-Sapsako T. WITHDRAWN: An anatomic aberration and a surgical challenge: Mediastinal parathyroid adenoma anterior the pericardium. A case report. <span><span class="ref-journal">Int J Surg Case Rep. </span>2019;<span class="ref-vol">57</span>:106-109.</span> [<a href="/pmc/articles/PMC6444067/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6444067</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30943449" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30943449</span></a>]</div></dd><dt>8.</dt><dd><div class="bk_ref" id="article-20885.r8">Lane MJ, Desser TS, Weigel RJ, Jeffrey RB. Use of color and power Doppler sonography to identify feeding arteries associated with parathyroid adenomas. <span><span class="ref-journal">AJR Am J Roentgenol. </span>1998 Sep;<span class="ref-vol">171</span>(3):819-23.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/9725323" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 9725323</span></a>]</div></dd><dt>9.</dt><dd><div class="bk_ref" id="article-20885.r9">Joliat GR, Guarnero V, Demartines N, Schweizer V, Matter M. Recurrent laryngeal nerve injury after thyroid and parathyroid surgery: Incidence and postoperative evolution assessment. <span><span class="ref-journal">Medicine (Baltimore). </span>2017 Apr;<span class="ref-vol">96</span>(17):e6674.</span> [<a href="/pmc/articles/PMC5413231/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5413231</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/28445266" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28445266</span></a>]</div></dd><dt>10.</dt><dd><div class="bk_ref" id="article-20885.r10">Miura D. Ectopic parathyroid tumor in the sternohyoid muscles: supernumerary gland in a patient with MEN type 1. <span><span class="ref-journal">J Bone Miner Res. </span>2005 Aug;<span class="ref-vol">20</span>(8):1478-9.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/16007345" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16007345</span></a>]</div></dd><dt>11.</dt><dd><div class="bk_ref" id="article-20885.r11">Park HL, Yoo IR, Kim SH, Lee S. Multiple endocrine neoplasia type 1 with anterior mediastinal parathyroid adenoma: successful localization using Tc-99m sestamibi SPECT/CT. <span><span class="ref-journal">Ann Surg Treat Res. </span>2016 Dec;<span class="ref-vol">91</span>(6):323-326.</span> [<a href="/pmc/articles/PMC5128379/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5128379</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27904855" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27904855</span></a>]</div></dd></dl></div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Bianca Georgakopoulos declares no relevant financial relationships with ineligible companies.</p></div></dd><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Yasir Al Khalili declares no relevant financial relationships with ineligible companies.</p></div></dd></dl></div><div class="bk_prnt_sctn"><h2>Figures</h2><div class="whole_rhythm bk_prnt_obj bk_first_prnt_obj"><div id="article-20885.image.f1" class="figure bk_fig"><div class="graphic"><img src="/books/NBK540972/bin/Gray1177.jpg" alt="Image Gray1177" /></div><div class="caption"><p>The Parathyroid Glands Henry Vandyke Carter, Public Domain, via Wikimedia Commons</p></div></div></div><div class="whole_rhythm bk_prnt_obj"><div id="article-20885.image.f2" class="figure bk_fig"><div class="graphic"><img src="/books/NBK540972/bin/Ectopic__parathyroid.jpg" alt="Image Ectopic__parathyroid" /></div><div class="caption"><p>Ectopic parathyroid glands Image courtesy S Bhimji MD</p></div></div></div></div></div></div>
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This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
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