Abstract Objectives: The goal of this report is to discuss a rare case of primary hyperparathyroidism secondary to a supernumerary ectopic intra-vagal parathyroid adenoma. Methods: Case report with discussion of current literature. Results: A 30-year-old female with primary hyperparathyroidism initially underwent neck exploration to resect a suspected adenoma based on the preoperative localization scan. Despite extensive neck exploration no adenoma was identified. Repeat localization scans and surgical re-exploration successfully identified a high cervical ectopic intravagal parathyroid adenoma. The adenoma was completely resected with a subsequent decrease in the patient’s calcium and parathyroid levels. Conclusion: This unusual case of primary hyperparathyroidism is only the seventh case reported in the English-language literature and highlights the challenges faced by head and neck surgeons when evaluating and treating this disease process. The variability inherent to parathyroid gland anatomy continues to create treatment dilemmas. Though rare, exploration of the vagus nerve should be considered as a possible location of a suspected ectopic adenoma.