Incidental lesions of the thyroid gland are an increasing problem facing clinicians. While asymptomatic palpable lesions are detected in only 4–7% of the population, currently available imaging modalities are sensitive enough to detect lesions in 20–30% of the population. Guidelines for managing these incidentalomas are limited, largely due to lack of well-powered prospective studies. This review will address the currently available data on thyroid incidentalomas, detected through clinical examination, cross-sectional imaging, ultrasound, and PET scans. We will focus on the modalities of detection and risk of malignancy, further investigation and management options and the deficiencies therein. We propose a pragmatic algorithm when faced with this clinical dilemma under differing circumstances.