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Real-time ultrasound (US) elastography (USE) assesses lesion stiffness and was reported as markedly accurate in thyroid nodule evaluation. The aim of this study was to validate the effectiveness of head and neck surgeon-performed USE in the evaluation of thyroid nodules. Methods: From January 2011 to November 2013, 308 patients with thyroid nodules who received traditional US, USE, and US-guided cytology were reviewed. The nodules with cytology reports that revealed Bethesda cytology levels of Thy 2, Thy 5, and Thy 6 were collected. The characteristics of traditional US and USE were analyzed. Results: Univariate analysis revealed that a set of characteristics including a larger transverse diameter, taller-than-wide shape, margins, heterogeneous echotexture, microcalcification, predominately solid echo structure, marked intranodular vascular pattern and USE (an elastography score of III/IV vs. I/II) differed significantly between malignancy and benignity (p < 0.05). Stepwise multivariate logistic regression analysis showed that a taller-than-wide shape, microcalcification, and USE were independent, significant factors in predicting malignant nodular disease (p < 0.05) Conclusion: The results support the hypothesis that USE is an independent factor in determining malignant thyroid nodules.