Aims: Thyroid lesions detected during nasopharyngeal carcinoma (NPC) evaluation may represent benign nodules, synchronous carcinoma, metastatic NPC, or radiation-associated malignancy. Misinterpretation can delay diagnosis and treatment, particularly when findings are assumed incidental. This study evaluated diagnostic pitfalls and management pathways for thyroid lesions identified during NPC workup or surveillance. Methodology: PubMed, Cochrane Library, and Google Scholar were searched for studies reporting thyroid lesions in NPC patients. Case reports, case series, observational and diagnostic accuracy studies, and systematic reviews were eligible. Extracted data included lesion detection timing, imaging findings, cytology/biopsy results, timing of diagnosis relative to radiotherapy, and treatment sequence. Results: Seven published reports and two index cases were identified (nine patients). Primary thyroid carcinoma occurred in seven patients (77.8%), metastatic NPC to the thyroid in one (11.1%), and benign adenoma with nodal metastatic NPC misdiagnosed as thyroid carcinoma in one (11.1%). Papillary carcinoma accounted for six of seven primary cancers (85.7%). Major pitfalls included delayed evaluation of suspicious findings, false reassurance from longstanding goiter or indeterminate cytology, and misattribution of lymphadenopathy to thyroid origin rather than NPC. Conclusion: Thyroid lesions in NPC patients should be evaluated as distinct diagnostic entities. Suspicious imaging, persistent structural abnormalities, multinodular disease, or indeterminate cytology warrant further investigation. Earlier thyroid assessment before radiotherapy may reduce diagnostic delay and support appropriate treatment sequencing.