Background Despite lack of evidence-based support, chest X-ray (CXR) prior to thyroid surgery is often used to identify tracheal deviation that may predict difficulty with intubation. The aim of this study is to establish the utility of preoperative CXR to assess tracheal deviation in this group of patients. Methods We analyzed a prospective database of 1,000 consecutive patients who underwent thyroid surgery. Patients' charts were reviewed for demographic data, CXR readings, other imaging findings, anesthesia records, and pathology findings. Patients with tracheal deviation (TD) on CXR were compared to patients without (no TD). Results Six hundred eighty-nine (69 %) patients had a CXR performed prior to surgery. TD was identified in 252 (37 %) patients while 437 (63 %) did not have TD. The two groups did not significantly differ in mean age, BMI, or gender. Patients with TD on CXR had larger thyroid glands (51 ± 4 vs. 28 ± 2 g, p < 0.001) and reported a higher rate of tracheal compressive symptoms (19 vs. 12 %, p = 0.005). However, this did not translate into more difficult intubations as reported by the anesthesiologist (5 vs. 7 %, p = 0.31) or more intubation attempts (1.2 ± 0 vs. 1.1 ±0, p = 0.1). Lung findings on CXR that resulted in further workup were identified in 32 (5 %) patients, with additional pathology found in only 6 (1 %) patients. Conclusion There is no correlation between a finding of tracheal deviation on preoperative CXR and difficult intubation in thyroid patients. Therefore, CXR for the sole purpose of identifying tracheal deviation in thyroid surgery candidates is not warranted. © Société Internationale de Chirurgie 2012.