Objective: Primary hyperparathyroidism (PHPT) is an uncommon endocrine disorder in children and adolescents, often presenting with pronounced clinical symptoms and significant biochemical abnormalities. This study aims to elucidate the clinical spectrum, diagnostic pathway, and therapeutic outcomes of pediatric PHPT through a combined retrospective cohort analysis and illustrative case reports. Methods: We retrospectively reviewed PHPT cases diagnosed between 2005 and 2022 at a tertiary university hospital, evaluating clinical manifestations, biochemical and imaging findings, treatment modalities, and long-term outcomes. In addition, we detail two distinctive pediatric cases highlighting the heterogeneity in clinical presentation and therapeutic approaches. Results: Among ten patients (mean age 16.3 ± 1.3 years), 80% were symptomatic at diagnosis, most commonly with skeletal pain or renal symptoms. Mean serum calcium was 13.6 ± 2.5 mg/dL, and PTH was markedly elevated (204.8 ± 163.1 pg/mL). All patients had solitary parathyroid adenomas confirmed histologically. Surgical parathyroidectomy led to cure in all cases, with no significant complications or recurrence over a mean follow-up of 10.4 ± 5.9 years. One patient experienced hungry bone syndrome postoperatively. Genetic testing for MEN1 was negative in both case studies. The two presented cases exemplify the diagnostic delay due to nonspecific symptoms—foot pain with osteolytic lesions in one, and emotional lability with abdominal pain in the other—underscoring the need for heightened clinical suspicion. Conclusions: PHPT in the pediatric population is rare but frequently symptomatic and more severe than adult-onset forms. Solitary adenoma remains the predominant etiology. Early recognition is crucial to prevent complications, particularly in pubertal patients with skeletal or neuropsychiatric symptoms. Surgery is curative in the majority of cases, with favorable long-term outcomes. These findings reinforce the need for clinical vigilance and multidisciplinary assessment in atypical presentations of hypercalcemia in youth.