Evidence-Based Approach to a “Missing” Parathyroid Gland during Thyroid or Parathyroid Surgery.

Rodrigo Arrangoiz MS, MD, FACS, FSSO

Arrangoiz, R., Cordera, F. and Zambrano, M. (2026) Evidence-Based Approach to a “Missing” Parathyroid Gland during Thyroid or Parathyroid Surgery. International Journal of Otolaryngology and Head & Neck Surgery , 15, 261-283.

https://doi.org/10.4236/ijohns.2026.154024

Abstract

Failure to identify a parathyroid gland during thyroidectomy or parathyroidec-

tomy represents a well-recognized intraoperative challenge and is most com-

monly explained by ectopic gland location rather than true agenesis. A com-

prehensive understanding of parathyroid embryology, migration patterns, and

cervical anatomy is therefore essential for safe endocrine neck surgery and for

minimizing failed explorations, hypoparathyroidism, and recurrent disease.

This review provides a practical and surgically oriented overview of the “miss-

ing” parathyroid gland, integrating embryologic development, anatomic vari-

ability, operative identification strategies, and contemporary nomenclature sys-

tems. The embryologic descent of the superior and inferior parathyroid glands

from the fourth and third pharyngeal pouches, respectively, explains the pre-

dictable distribution of ectopic glands encountered during surgery. Superior

glands typically maintain relatively constant locations near the posterior as-

pect of the upper thyroid pole, whereas inferior glands demonstrate greater po-

sitional variability because of their longer migratory course with the thymus.

Common ectopic locations include the tracheoesophageal groove, retroesopha-

geal space, thyrothymic ligament, cervical thymus, carotid sheath, retropha-

ryngeal region, mediastinum, and intrathyroidal or subcapsular locations. This

review emphasizes operative pearls for gland identification, including recog-

nition of key landmarks such as the inferior thyroid artery, recurrent laryngeal

nerve, prevertebral fascia, cervical thymus, and characteristic parathyroid fat

pads. Strategies for systematic exploration are discussed in the context of both

thyroidectomy and parathyroidectomy. Additionally, the manuscript reviews

the Perrier classification system for ectopic parathyroid glands and proposes

DOI: 10.4236/ijohns.2026.154024 Jul. 9, 2026 261 Int’l J. of Otolaryngology and Head & Neck SurgeryR. Arrangoiz et al.

its practical application during cervical exploration to facilitate structured lo-

calization of missing glands. By combining embryologic principles with oper-

ative anatomy and contemporary surgical nomenclature, this review aims to

provide endocrine surgeons, trainees, and head and neck surgeons with a clin-

ically relevant framework for identifying orthotopic and ectopic parathyroid

glands, reducing operative failure, and improving surgical outcomes in thy-

roid and parathyroid surgery.

Keywords

Parathyroid Gland, Ectopic Parathyroid Gland, Missing Parathyroid Gland,

Parathyroid Embryology, Thyroidectomy, Parathyroidectomy, Mediastinal

Parathyroid Gland, Intrathyroidal Parathyroid Gland, Perrier Classification,

Surgical Anatomy, Parathyroid Localization

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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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