In the tropics thyroid surgery is carried out either by general surgeons or ear, nose and throat surgeons and there are few places with a subspecialist endocrine or head and neck surgeon. The aim of this review is to determine the pattern of thyroid pathology, surgery and surgical outcomes in the tropics. A review of thyroid surgery in tropical regions was carried out based on published articles in English in Medline (1965-2004). The findings are also discussed in the light of the authors' own experience of thyroid disease and thyroid surgery in four continents. The pattern of thyroid pathology varies in the tropics, particularly in regions where endemic goitre is common. Endemic goitre usually regresses with iodine therapy. There is a rising incidence of thyroid autoimmune disease, particularly Graves' disease and Hashimoto's thyroiditis, probably related to an environmental immunological stimulus associated with development. Surgery is indicated for the same reasons as in the developed countries: thyrotoxicosis (more often in the absence of radioactive iodine therapy), solitary thyroid nodule and multinodular or malignant goitre. However, a preoperative cytological diagnosis will only be available in important centres where there is a pathologist. Malignancy appears more prevalent in nodules and goitres in the tropics than in the developed countries, perhaps because patients with malignancy are more likely to be referred to a surgeon. Nonetheless, the evidence suggests that thyroid surgery can be carried out safely with a minimum of complications even in remote mission hospitals with limited facilities for investigation. Standards can be set in terms of surgical outcomes; for example, mortality (0%), permanent recurrent laryngeal nerve (RLN) injury (<2%), re-exploration for haematoma(<2%), permanent hypocalcaemia (<5%) and wound infection (2.5%). The choice of operation depends on the local pathology and the likelihood of being able to obtain lifelong thyroxine. Total thyroidectomy should be avoided whenever possible if thyroxine supplies are unreliable. Advanced thyroid cancer presents a therapeutic challenge and some cases will be unresectable. The management options are limited by the resources available. Similar surgical outcomes should be able to be achieved no matter where the surgery is carried out.