Can the parathyroid gland be evaluated with ultrasound?

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Last updated: March 13, 2026 • View editorial policy

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Can Ultrasound Evaluate the Parathyroid Gland?

Yes, ultrasound is widely utilized and highly effective for evaluating parathyroid glands, and is considered the preferred initial imaging modality for primary hyperparathyroidism by major endocrine surgery societies. 1

Role of Ultrasound in Parathyroid Evaluation

Primary Hyperparathyroidism (PHPT)

  • Both the American Head and Neck Society Endocrine Surgery Section and the American Association of Endocrine Surgeons deem ultrasound to be the preferred initial localization study in patients with PHPT, with the key advantage of allowing concomitant thyroid evaluation 1

  • Performance characteristics are robust: A 2012 meta-analysis of 19 studies revealed a pooled sensitivity of 76% and positive predictive value (PPV) of 93%, while a subsequent 2017 meta-analysis of 12 studies showed improved pooled sensitivity of 80% 1

  • Individual study sensitivities range widely from 44% to 97%, reflecting operator dependence and technical factors 1

Technical Capabilities and Advanced Features

Ultrasound can identify both abnormal and normal parathyroid glands:

  • Normal parathyroid glands can be detected in 81.79% of subjects, typically appearing as oval-shaped hyperechoic nodules (79.29% hyperechoic, 20.71% isoechoic) with minimal blood flow (grade 0-I in 86.71%) 2

  • Pathological parathyroid adenomas characteristically appear as hypoechoic, well-contoured lesions with increased central echogenicity (44.3%), peripheral-central vascularization (47%), and a polar feeding vessel (100%) 3

Enhanced Ultrasound Modalities

Advanced ultrasound techniques significantly improve diagnostic accuracy:

  • Low-frequency vascular probes identify 20% more feeding vessels, 27% more polar placements of feeding vessels, and 65% more vascular arches compared to conventional high-frequency probes, facilitating detection of hyperfunctioning parathyroid glands 4

  • Shear wave elastography (SWE) demonstrates that parathyroid adenomas have lower tissue stiffness (SWV 1.67-1.77 m/second) compared to adjacent thyroid tissue (SWV 2.3 m/second), enhancing diagnostic confidence 5

  • Contrast-enhanced ultrasound (CEUS) achieves 90.9% sensitivity and 72.7% specificity for differentiating parathyroid lesions, improving to 98% sensitivity and 80% specificity with quantitative analysis 3

  • 3D ultrasound with color Doppler may improve visualization of the polar artery and enhance differentiation from lymph nodes 5

Limitations and Clinical Considerations

Common causes of non-localization by ultrasound include:

  • Ectopic or far posterior location of adenomas 1
  • Multiglandular disease 1
  • Small adenoma size 1
  • Concomitant thyroid disease 1

Factors affecting parathyroid display:

  • Body mass index (BMI) 2
  • Thyroid echogenicity 2
  • Thyroid volume 2

Pediatric Population

  • Limited data exists, but sensitivity improves with age: false-negatives occurred in 2 neonates, while sensitivity reached 93% in older children 1
  • In a separate pediatric study, ultrasound sensitivity was 60% 1

When Ultrasound Is Insufficient

For recurrent or persistent hyperparathyroidism after surgery, multiple imaging modalities may be utilized in combination to maximize accuracy and confidence of parathyroid localization via concordant imaging results 1

Selective parathyroid venous sampling is reserved for reoperative surgical candidates when noninvasive examinations (ultrasound, sestamibi, CT) yield nonlocalizing, equivocal, or discordant results 1

References

1
Guideline

acr appropriateness criteria® parathyroid adenoma.

Journal of the American College of Radiology, 2021

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