For patients with persistent or recurrent hyperparathyroidism, parathyroid imaging is indicated to confirm the presence of abnormal parathyroid gland(s) and identify their location. These imaging techniques are being modified constantly and newer methods have been developed. Sestamibi scintigraphy, MRI and sonography were compared in 23 patients with persistent or recurrent hyperparathyroidism. Preoperative 99m-Technetium Sestamibi (MIBI), MRI and ultrasonographic (US) studies of 23 patients with 25 histopathologically confirmed abnormal parathyroid glands were compared, using independent prospective interpretations. All patients had been operated upon previously for hyperparthytroidism. Accuracy of various combinations of MRI, MIBI, and US also were calculated. The results are shown for all abnormal glands (n =25); sensitivities and accuracies were 88 and 84% for MRI, 80 and 80% for MIBI, and 58 and 44% for US. For only parathyroid adenomas (n = 18), sensitivities and accuracies were 89 and 89% for MRI, 94 and 94% for MIBI, and 58 and 39% for US. Finally, for parathyroid hyperplasia (n = 7 glands in five patients), sensitivities and accuracies were 83 and 71% for MRI, 43 and 43% for MIBI, and 57 and 57% for US. Either MIBI or MRI results were significantly better for detecting abnormal parathyroid glands than US (P < 0.01), but MRI and MIBI were not statistically different. Combining MRI and MIBI produced a combined accuracy of 92%, whereas combining either of these tests with US did not improve on the accuracy of either test alone. In conclusion, for patients with persistent or recurrent hyperparathyroidism, MRI and MIBI are equally accurate for detecting abnormal parathyroid glands, and the combination of both tests may be more accurate than either test alone.