Background Differentiated thyroid malignancies have a generally positive prognosis, however some forms (e.g. oncocytic thyroid carcinoma, previously known as Hurthle cell thyroid carcinoma) are poorer. We report on an interesting case of oncocytic thyroid carcinoma presenting with an enormous goitre causing significant airway distortion. Case report A 51-year-old male presented to our healthcare network with falls, and 4 days of lower limb weakness and parasthesia. He reported also having a large right neck mass for the past 5 years, which had rapidly grown to an enormous size (>25cm) over the past 3 months. Examination revealed an at least 25cm fixed right neck mass with impalpable neck landmarks. Nasoendoscopy revealed a large right parapharyngeal swelling completely occluding and displacing the larynx laterally. Cross sectional imaging and biopsy confirmed an enormous oncocytic thyroid carcinoma with spinal metastases and cord compression. The patient continued to deteriorate and passed away two days later. Discussion This is an interesting case of significantly advanced differentiated thyroid carcinoma. Given differentiated thyroid carcinoma has a generally good prognosis, This patient was able to survive at least 4 years with this thyroid malignancy with minimal impact to his daily activities. Advanced malignancies such as these are an uncommon presentation that offers unique and complex airway planning issues. Conclusion Differentiated thyroid malignancies including oncocytic thyroid carcinoma have a generally good prognosis, however advanced presentations do occur, and provide an interesting and challenging case for surgical and airway management.