The age of the patients at the time of diagnosis ranged from 48 to 77 years, with a mean age of 66.3 years, only one patient (11%) was from the age group of 40 to 60 years, while the remaining eight (89%) were from 60 to 80 years.

There was a female predominance in our cohort: 7 women (78%) and 2 men (22%), with sex ratio (M/F) of 0.3.

All female patients were post-menopausal. Three of our patients were previously diagnosed with primary hyperthyroidism, five patients (55%) had a history of hypertension. One patient presented with a history of hyperthyroidism. Two patients had undergone abdominal surgery one for nephrolithiasis and the other for cholelithiasis. A history of miscarriage was reported in three female patients (33%), one patient (11%) reported alcohol consumption, no history of smoking was reported among the patients.

Seven patients (78%) presented with generalized inflammatory bone pain, often associated with diffuse myalgia. One patient (11%) reports arthralgia. Five patients (56%) describe muscle cramps in the lower limbs. Four patients (44%) experienced palpitations. Constipation was reported by three patients (33%) during the months preceding their consultation. One patient (11%) presented with epigastric pain. In one case, hypercalcemia was incidentally discovered during routine laboratory tests performed as part of anemia workup.

Six patients (67%) presented with deterioration of general condition, the symptoms included fatigue, unquantified weight loss, unspecified anorexia. One patient (11%) exhibited mental disturbances. A gait abnormality was observed in one patient (11%).

Serum parathyroid hormone (PTH) concentration was measured in seven patients. In four cases, the value was twice the upper limit of the normal range. In the remaining three cases, PTH levels were mildly elevated: 69.96 and 94 pg/mL respectively. Serum calcium concentration ranged from 106 to 165 mg/mL, with a mean value of 135.5 mg/mL. Hyperphosphatemia was detected in one patient (11%). Elevated 24-hour urinary calcium (>6.25 mmol/24 h). Excretion was observed in two cases. Serum alkaline phosphatase was elevated in two patients (>125 UI/l). All patients had a normal renal function.

Six patients underwent cervical USG, revealing a single parathyroid nodule in all cases (100%), and associated thyroid nodules in two cases (33%).

Five patients underwent a cervical CT scan, which also revealed a single parathyroid nodule in each case. Associated thyroid nodules were observed in 2 cases.

All patients received appropriate preoperative preparation, including rehydration, diuretic therapy, and monitoring of both cardiac and renal functions. Each patient in our series underwent parathyroidectomy through a standard transverse cervicotomy ( Figure 2 ) with excision of a single parathyroid nodule.

Although the location varied, the lesions were predominantly located in the inferior parathyroid glands (89%) ( Figure 3 ), illustrates the distribution of patients based on the surgical procedure performed.

A lobo-isthmectomy and a total thyroidectomy were performed in two cases (22%).

The post-operative course was uneventful for all patients ( Figure 4 and Figure 5 ), with normalization of serum calcium levels. Vomiting was observed in one case, which resolved after the administration of antiemetics.

Two months postoperatively the patients returned with normal serum calcium and phosphorus levels

During the 5 years follow-up, no recurrence was observed. clinical examination was normal, total calcium (2.2 to 2.6 mmol/l) and PTH levels (15 to 65 pg/ml) were normal.

In our series, histopathology revealed a single parathyroid adenoma in all cases (100%) ( Figure 6 ).

Claire BLANCHARD-LOUIS in Nantes reported a mean age of 68 years [4] . HARIGA et al. in Tunisia observed a mean age of 56.5 years [5] . Both studies noted that the age at the diagnosis was over 50 years, which was also the case in our series.

Our cohort showed a female predominance with 78% female and 22% male patients. Table 1 presents the predominant sex reported by various authors.

n: Number of cases.

Primary hyperparathyroidism can be discovered through various clinical presentations:

In our series, all patients initially sought consultation in general medicine. The most common symptoms of hypercalcemia including fatigue, weight loss and osseous manifestations were observed in 78% of cases.

One patient was asymptomatic, with hypercalcemia discovered incidentally.

Our findings differ from those of M. KHEDER [7] who found that the majority of the cases were discovered through hypercalcemia in laboratory tests, most of which were asymptomatic.

In the present study, osseous manifestations were the most common (78%), including bone pain, arthralgia, and abnormal gait. General symptoms were the second most frequent (67%), such as fatigue and weight loss. One case of depressive disorder (11%) was noted. Table 2 summarizes the clinical signs reported in various international studies.

n: Number of cases.

In our series, serum calcium levels were above the normal range in 100%, as were iPTH levels. Two patients had elevated 24-hour urinary calcium excretion.

In 2007 HARIGA et al. [5] reported that 92% of their patients had elevated serum calcium levels with a mean range of 115mg/L. 24-hour urinary calcium excretion was above the normal range in 72% of the patients and normal in 28%. iPTH were elevated in 100% with a mean value of 405 pg/mL

In the 2007 series of M Tassart et al. [8] in Paris, the sensitivity of the USG was 85%.

Our results are higher with a sensitivity of 100% of USG. However, the size of our simple requires some cautions.

In our series, a CT scan was conducted in five patients and confirmed the diagnosis in all cases, resulting in sensitivity of 100%. As reported by the authors the sensitivity and specificity of the CT scan are 70% and 90% respectively, slightly more accurate compared to ultrasound [9] .

There are two main approaches:

In our series, all patients who presented with hypercalcemia (100%) received hypocalcemic treatment consisting of furosemide and rehydration. Moreover, no patient received bone-targeted or etiological treatment.

A parathyroidectomy with excision of a single nodule was performed in 100% of the cases. The nodule exhibited variable locations, with a predominance in the inferior parathyroid region.

HARIGA [5] also realized excision of a single nodule in 88% of the cases.

In our series, parathyroid adenoma accounted for 100% of the cases.

Table 3 compares our results of histological findings with those of international series.

In all international series, as well as in ours, parathyroid adenoma is by far the most commonly found pathological lesion in pHPT.

The post-operative course was uneventful in the majority of the cases 98% [ 15] .

However, a strict monitoring protocol should be implemented:

-Clinical monitoring: assessing for hypocalcemia signs such as muscle cramps, tingling in the extremities, paresthesia, and numbness.

-Biological monitoring: immediate postoperative monitoring of serum calcium levels on Day 0, Day 1 and Day 8 [16] .

Acute hypocalcemia and recurrent laryngeal nerve paralysis [12] [13] are the main immediate postoperative complications. Serum calcium levels typically drop the most between the first and the third postoperative days.

In Barbier et al. [13] multicenter study, the rate of permanent recurrent laryngeal nerve paralysis in 1.5% in 4883 patients who underwent traditional cervicoctomy.

In our study, no cases of hypocalcemia, recurrent laryngeal nerve paralysis, or hematoma were reported. similarly, no late complications such as postoperative hypoparathyroidism, renal insufficiency or acute pancreatitis were observed.

Proye, in a series of 1888 patients, a 97.6% success rate was attained after primary standard cervicotomy [17 ] . This rate is close to those typically reported in other series, which range around 95% [18] .

In our study, we achieved a 100% success rate with classic cervicotomy, with full recovery.

The risk of failure can be minimized by exploring the ipsilateral gland and searching for an ipsilateral supernumerary gland. The causes are multiples. Table 4 presents the main causes of primary hyperparathyroidism recurrence.

In our series, there was no recurrence observed during the 5 years follow up period.

The findings from our study align with data from international cohorts, which demonstrate a very low recurrence rate following surgical treatment [5] [17] . According to our results, transverse cervicotomy has demonstrated its effectiveness and remains an efficient and accessible therapeutic approach our countries, until minimally invasive surgery [19] [20] become more widely available.