Involvement of the recurrent laryngeal nerve (RLN) by well-differentiated thyroid carcinoma may not invariably lead to unilateral cord palsy, although the presence of RLN palsy is associated with locally advanced disease. The present study evaluates the clinicopathologic features and outcomes of patients surgically treated for well-differentiated thyroid carcinoma with documented nonfunctioning RLN at presentation. From 1970 to 2002, 20 of 709 patients undergoing surgical treatment for well-differentiated thyroid carcinoma were found to have ipsilateral unilateral cord palsy by routine preoperative laryngoscopy. There were 5 men and 15 women with a median age of 70 years. Nine patients (45%) did not have a clinically palpable thyroid mass, and hoarseness was the primary presenting symptom. All patients had histologically confirmed pT4 papillary thyroid carcinoma with a median size of 4 cm. Cervical nodal and pulmonary metastases were detected in 14 (70%) and 2 (10%) patients, respectively. The ipsilateral recurrent nerve was transected in all patients because of gross tumor involvement, and 19 patients underwent total or completion total thyroidectomy. Resection was incomplete in 15 patients, including 2 who underwent a debulking procedure and required reoperation for local control. Postoperative radioactive iodine ablation and external-beam irradiation were administered to 18 and 13 patients, respectively. Over a median follow-up of 4.5 years, 10 patients survived without evidence of recurrence, 5 died of disease recurrence, and 5 died of unrelated causes. The 5-year and 10-year cause-specific mortality was 17% and 42%, respectively. Patients developing distant metastasis at presentation or during follow-up had a significantly increased cause-specific mortality (p = 0.002). Preoperative RLN palsy can be the first symptom in patients with locally advanced papillary thyroid carcinoma. Despite the adoption of a relatively conservative surgical treatment, long-term survival can be achieved in selected patients.