Objective <p>Selecting patients with cT1N0M0 papillary thyroid carcinoma (PTC) for prophylactic central neck dissection (pCND) remains a challenge. This study aimed to identify predictive factors for occult central lymph node metastasis (oCLNM) in patients undergoing transoral endoscopic thyroidectomy vestibular approach (TOETVA).</p> Methods <p>This cross-sectional, propensity score-matched study included 80 patients with cT1N0M0 PTC who underwent TOETVA with pCND at Hanoi Medical University Hospital between March 2023 and March 2024. Patients were divided into two matched groups (<i>n</i> = 40 each) based on the presence or absence of oCLNM on final pathology. Baseline characteristics were comparable (<i>p</i> &gt; 0.05).</p> Results <p>The metastatic group had a significantly higher median number of harvested lymph nodes than the non-metastatic group (5.5 vs. 4.0; <i>p</i> = 0.018). No significant associations were found for tumor size, multifocality, or microscopic extrathyroidal extension (mETE). All five cases of bilobar tumors were observed in the metastatic group. Surgical outcomes, including operative time, blood loss, and hospital stay, were similar between groups.</p> Conclusion <p>The number of harvested lymph nodes is associated with the detection of oCLNM, while the presence of a bilobar tumor may also be a predictive factor. However, reliably predicting oCLNM preoperatively remains difficult. Larger studies are needed to develop more accurate predictive models for selecting patients for pCND.</p>