Background: Recurrent laryngeal nerve (RLN) palsy is a major complication after thyroidectomy. Early detection before extubation may help anticipate airway compromise and guide timely management. Transcutaneous laryngeal ultrasonography (TLUSG) offers a noninvasive bedside option, but its pre-extubation utility remains insufficiently studied. This study aimed to evaluate the inter-rater reliability and diagnostic performance of pre-extubation ultrasound for detecting RLN palsy after thyroidectomy, using post-extubation video-assisted laryngoscopy as the reference standard. Methods: This prospective observational study included 30 adults undergoing elective thyroidectomy under general anesthesia. Vocal cord mobility was assessed before extubation by ultrasound and independently interpreted by three raters; a consensus assessment was also generated. After extubation, vocal cord mobility was reassessed using video-assisted laryngoscopy. Results: Video-assisted laryngoscopy confirmed RLN injury in 5/30 patients (16.7%). Pre-extubation ultrasound identified RLN injury in 20.0%, 16.7%, and 13.3% of patients by raters 1, 2, and 3, respectively. Overall inter-rater agreement was fair (Fleiss’ Kappa [κ]=0.28, P=0.008). Agreement with the reference standard was highest for rater 3 and the consensus assessment (κ=0.609, P=0.009). Both showed 60.0% sensitivity, 96.0% specificity, 75.0% positive predictive value, 92.3% negative predictive value, and 78.0% accuracy. RLN injury was significantly associated with male sex and longer operative duration. Conclusion: Pre-extubation ultrasound is a feasible, safe, and noninvasive adjunct for RLN assessment after thyroidectomy. Its high specificity and negative predictive value support bedside screening use, but modest sensitivity and operator dependence limit its role as a standalone alternative to laryngoscopy.