Introduction: Real-time elastography is an imaging method that adds quality to the diagnosis of nodular thyroid lesions. Meta-analysis data suggest a good diagnostic performance with an overall specificity of 80% and sensitivity of 85%. The present study is a retrospective analysis of the most common causes of false negative and false positive results encountered in thyroid ultrasound. Material and methods: We analyzed 433 nodular lesions, operated and evaluated by classical thyroid ultrasound and elastography, using a linear probe on a Hitachi Preirus machine, Hitachi Inc., Japan: The results of the ultrasound were not communicated to the pathologist. A retrospective analysis of the results was performed. Results: We evaluated 433 thyroid nodules with an average volume of 2.14 ml (ranging from 0.78 ml to 10.45 ml). 134/433 cases were identified with thyroid cancer and 251/434 were identified as benign lesions. The sensitivity of the elastography was 82.02%, the specificity – 83.94%, the accuracy being 83.37%. We observed 48 cases of benign lesions, identified by elastography as suspicious lesions : 23/48 – lesions with Hürthle cells, without vascular diseases, 8/48 – proliferative lesions potentially uncertain, 5/48 – follicular proliferation, 8/48 – myxomatous / granulomatous thyroiditis and 12/48 cases of autoimmune thyroid disease. We also noted 24 false negative results: 19 / 24 – papillary microcarcinomas, 5/25 – follicular carcinomas. Of note is that microcarcinomas that have been observed in nodules, had > 3.5 cm in diameter. Conclusions: Hurtle cell proliferations and papillary microcarcinomas are the most common misdiagnosed conditions in thyroid elastography.