Background: Recurrent laryngeal nerve palsy (RLNP) after total thyroidectomy (TT) is a potentially life-threatening complication with medicolegal implications and remains underestimated. Temporary bilateral RLNP can cause acute airway obstruction, while permanent palsy persisting beyond 6 months post-TT causes long-term morbidity. This cohort study determined the incidence and clinicopathological risk factors of unilateral and bilateral RLNP in patients undergoing TT. Patients and methods: Surgical candidates (n = 812, male: female = 110:702) were assessed for vocal cord (VC) status with videolaryngoscopy preoperatively, at 72 hours, and 6 months post-TT. Serum corrected calcium and parathormone were also assessed. Demographics, surgical time, intraoperative RLN identification, and histopathology were noted. Results: Unilateral and bilateral RLNP were observed in 8 (1%) and 4 (0.5%) patients preoperatively, 56 (6.9%) and 15 (1.8%) patients postoperatively, and 11 (1.4%) and 6 (0.7%) patients after 6 months. On multivariate analysis, major determinants of unilateral temporary palsy were Hashimoto's/lymphocytic thyroiditis [odds ratio (OR) = 7.4], malignancy (OR = 4.6), and Graves’ disease (OR = 3.9), while RLN nonvisualization (OR = 8.9) predicted bilateral palsy, each p < 0.05. Intraoperative RLN injury (OR = 38.1) independently predicted permanent palsy. In receiver operative characteristic analysis, surgical time and 48-hour calcium predicted RLNP at cut-points of 127 minutes and 1.94 mmol/L, respectively, with area under the curve ≥0.8, each p < 0.01. Conclusion: Routine pre- and postoperative videolaryngoscopy identified the true incidence of RLNP, which was relatively high. Intraoperative RLN identification improved long-term outcomes at an increased risk of temporary palsy. RLN nonvisualization, prolonged surgery, transient hypocalcemia, malignancy, Graves’ disease, and thyroiditis were determinants of temporary palsy, while RLN injury or transection independently predicted permanent RLNP post-TT. Clinical significance: Routine intraoperative RLN visualization during thyroidectomy and postoperative videolaryngoscopy should be implemented in clinical practice. It provides accurate information for clinical audit of performance, particularly in teaching hospitals. Malignancy, Graves’ disease, and thyroiditis, which carry an increased risk for RLNP, should be managed by high-volume surgeons.