The incidence of papillary thyroid cancer is rising, with an increase in the number of microcarcinomas being discovered. There is controversy in the literature regarding the optimal management of these tumours. This study aimed to review our institution's experience with the presentation and management of papillary thyroid microcarcinoma. Retrospective analysis from the Sydney Head and Neck Cancer Institute, from 1987 to 2009. A total of 228 patients were analysed. Papillary thyroid microcarcinomas were discovered incidentally in 116 (50.9 per cent) patients and non-incidentally in the remaining 112 (49.1 per cent) patients. Amongst the non-incidental group, 11.6 per cent of patients presented with lateral cervical lymph node involvement. Non-incidental microcarcinomas were significantly associated with younger age (<45 years) (p = 0.007) and larger tumours (5-10 mm) (p < 0.001). Only four patients in the incidental group suffered recurrent disease (locoregional). No patient developed distant metastatic disease or died during follow up. Papillary thyroid microcarcinomas present both incidentally and non-incidentally, with equal prevalence. Non-incidental tumours not infrequently present with cervical lymph node disease. The patient outcome is generally excellent.