The incidence of small thyroid malignancy has increased. However, there is no evidence-based guideline for managing thyroid nodules ≤ 5 mm on ultrasonography (US). We evaluated how to manage thyroid nodules ≤ 5 mm. Thyroid nodules ≤ 5 mm in size on US that had undergone surgery and US-guided fine-needle aspiration were eligible. A total of 3,117 thyroid nodules in 3,012 patients were included. The size changes of malignant and benign nodules during follow-up were evaluated. Thyroid malignancies were classified according to follow-up and surgery time within and after 12 months. Clinico-pathological characteristics were compared. Of 3,117 nodules, 1,639 nodules in 1,619 patients were benign and 1,478 in 1,427 were malignant. Only 5.8 and 1.2 % of malignant nodules and 6.8 and 4.2 % of benign nodules increased in size when a 2-mm and 3-mm change on US were referenced. Of 1,079 patients with an index malignancy ≤ 5 mm, extrathyroidal extension, lymph node metastasis, recurrence, and mortality were not significantly different between patients with and without follow-up and between patients with surgery within 12 months and after 12 months. None of the patients who underwent surgery had distant metastasis and none died of thyroid malignancy. In thyroid nodules ≤ 5 mm found on US, US-FNA could be recommended in cases of increased size during US follow-up if lateral LNM was not found because a delay in surgery did not impact cancer recurrence and mortality.