Thyroid nodular disease represents one of the most prevalent endocrine disorders worldwide, with increasing detection rates due to the widespread use of high-resolution ultrasonography. While most thyroid nodules are benign and clinically insignificant, a subset may cause local symptoms or be malignant and require appropriate management. Historically, surgery has been the primary therapeutic approach, but advancements in minimally invasive procedures have shifted the paradigm toward more personalized treatment strategies. Among these, image-guided thermal ablation techniques—including radiofrequency ablation (RFA), laser ablation (LA), microwave ablation (MWA), and high-intensity focused ultrasound (HIFU)—have emerged as effective and safe alternatives for managing both benign thyroid nodules and select cases of recurrent thyroid cancer. This chapter explores the evolution of thermal ablation in thyroid disease management, emphasizing patient selection, procedural techniques, and clinical outcomes. The comprehensive assessment of thyroid nodules, utilizing ultrasound-based risk stratification systems such as TI-RADS and EU-TIRADS, plays a crucial role in determining appropriate candidates for thermal ablation. Fine-needle aspiration cytology (FNAC) remains pivotal for confirming benignity, while the incorporation of molecular testing has further refined diagnostic accuracy, particularly in indeterminate cytology cases. Radiofrequency ablation, the most widely adopted technique, demonstrates excellent efficacy in reducing nodule volume and alleviating symptoms, with a favorable safety profile and minimal impact on thyroid function. Laser ablation, predominantly used in Europe, offers precise energy delivery and comparable clinical outcomes. Microwave ablation provides rapid heating and larger ablation volumes, making it suitable for highly vascularized nodules. High-intensity focused ultrasound, a noninvasive technique, holds promise for superficial nodules but remains limited by depth and calcification challenges. Key procedural innovations, such as the moving-shot technique, trans-isthmic approach, and hydrodissection, have enhanced the safety and efficacy of thermal ablation. Contrast-enhanced ultrasound (CEUS) has emerged as a valuable tool for real-time evaluation of ablation completeness and long-term monitoring. Clinical applications extend beyond benign nodules to include autonomous functioning thyroid nodules (AFTN), papillary thyroid microcarcinoma (PTMC), and locally recurrent thyroid cancer. In benign nodules, thermal ablation offers significant symptom relief and cosmetic improvement, with sustained volume reduction rates exceeding 70% at 12 months. For AFTN, ablation presents an alternative to radioiodine therapy and surgery, particularly in patients seeking to avoid radiation exposure. In PTMC, thermal ablation provides a middle ground between active surveillance and surgery, offering oncologic safety with reduced complications and preservation of thyroid function. The chapter also addresses complications, emphasizing the importance of operator experience and patient selection. Major complications are rare, with transient voice changes being the most common. The long-term preservation of thyroid function and the low risk of hypothyroidism are key advantages of thermal ablation over traditional surgery. Looking ahead, advancements in artificial intelligence (AI) and fusion imaging are poised to further enhance the precision and efficacy of thyroid ablation procedures. AI-assisted systems can optimize electrode positioning and predict treatment outcomes, while fusion imaging improves visualization of challenging nodules. In conclusion, image-guided thermal ablation represents a transformative approach in thyroid nodule management, bridging the gap between conservative management and surgical intervention. Continued research and technological innovations will further refine patient selection criteria, procedural techniques, and long-term outcomes, solidifying thermal ablation’s role in personalized thyroid care.