Purpose The tall cell variant of papillary thyroid cancer (TCVPTC) is the most common variant. There is debate whether its prognosis is due to adverse histological features such as lymphovascular invasion (LVI) or lymph node metastasis rather than subtype alone. Methodology From 2003-2020, 97 patients with TCVPTC (defined as a height-to-width ratio of ≥3:1) and at least 30% tall cells were compared against 390 classical papillary thyroid carcinoma (CPTC). Survival analysis was performed with multivariable modelling initially. Propensity scoring was then performed with a 2:1 case matching as subgroup analysis to account for adverse histological features. Disease free survival was the primary outcome Results TCVPTC are more likely to present with adverse histological characteristics which predict an increased risk of recurrence, LVI (HR 2.24 p=0.02, lymph node involvement (HR 5.78 p<0.001) and multifocality (HR2.13 p=0.32). However, after propensity scoring and matching for lymphovascular invasion and lymph node involvement, there was no significant difference in risk of recurrence (OR 1.06 95%CI 0.98-1.10 p=0.14). TCVPTC tumors without adverse histological characteristics were smaller (<2cm). Conclusion TCVPTC tumours (<2cm) are not at increased risk of recurrence compared to CPTC if no other adverse clinicopathological factors are present. The presence of nodal disease and vascular invasion are independent predictors of a significantly increased risk of recurrence.