Objective To explore the protection of the structure and function around the upper pole of the thyroid gland by endoscopic thyroidectomy combined with nerve detection through the gasless unilateral axillary approach. Methods From January 2019 to June 2020, 48 thyroid patients who underwent the gasless unilateral axillary approach combined with the endoscopy and nerve detection technology in the Department of Head and Neck Surgery of Zhejiang Provincial People’s Hospital were reviewed as the endoscopic group, and 53 thyroid patients underwent open surgery combined with the endoscopy and nerve detection technology as the open group. The protection of the functional structure of the suprathyroid pole were compared. Results In terms of operation time, the endoscopic group was longer than that of the open group (67.5 min vs. 54.1 min, P=0.001). There was no statistical difference between the two groups in terms of postoperative hospital stay and blood loss (P>0.05). Forty-seven patients with the endoscopic thyroid surgery through the gasless unilateral axillary approach effectively detected the superior laryngeal nerve (47/48, 97.9%), which was higher than that of the open group (40/53, 75.5%), P=0.003, and the exposure rate of hypoglossal nerve descending branch in the endoscopic group was also higher [31.3% (15/48) vs. 3.8% (2/53), P=0.001]. In the endoscopic group, the superior parathyroid gland was kept in situ during the operation, and there was no change of voice and cough after the operation. In the open group, there were 2 cases of autologous transplantation of the upper pole parathyroid gland, 2 patients had voice changes, and 1 case had partial upper pole banded muscle incision. There was no significant difference in the incidence of nerve injury complications, the rate of autologous transplantation of the upper pole parathyroid gland and the rate of anterior cervical banded muscle injury between the two groups (P>0.05). In addition, there was no significant difference in the levels of parathyroid hormone, blood calcium, blood magnesium and blood phosphorus between the two groups before/after operation (P>0.05). Conclusion During the endoscopic thyroidectomy through the gasless unilateral axillary approach, the nerve monitoring technology is combined with the exploration and protection of the superior laryngeal nerve on the surface of the medial cricothyroid muscle of the upper pole of the thyroid, and the fine capsule anatomy technology is used to protect the superior parathyroid gland in situ, which can more effectively expose the external branch of the superior laryngeal nerve. It is conducive to the protection of the structures around the upper pole.