The following is a case of a 31-year-old otherwise healthy female with metastatic papillary thyroid carcinoma. Pre-operative ultrasound demonstrated a hypoechoic nodule in the right inferior lobe (7mm), and an enlarged level 3 node with cystic degeneration (16mm). She underwent total thyroidectomy with central and right modified radical lymph node dissection. A nerve monitoring endotracheal tube was used. The case was complicated by complete encasement of the right recurrent laryngeal nerve by tumor. Meticulous neurolysis was carried out to preserve the nerve. All macroscopic tumor was removed from the nerve and surgical field. There was no loss of nerve signal during the case, and the patient had no changes to her voice post operatively. The decision to preserve or sacrifice the nerve in the setting of direct tumor involvement is complex. Tumor invasion is most common with papillary thyroid cancer and is estimated to occur in 13-15% of all cases of differentiated thyroid cancer. Invasion of the recurrent laryngeal nerve has not been shown to independently impact survival. Importantly, nerve preservation has not been shown to have worse outcomes compared to nerve resection, and patients report improved functional outcomes with preservation. In our case, nerve preservation allowed the patient to avoid the morbidly of vocal cord paralysis and maintain her quality of life. The case was challenging due to extent of tumor involvement, but demonstrates a positive outcome in the setting of locally advanced disease.