Background: Elastosonography is a promising non-invasive technique that developed in recent years for evaluating thyroid nodules. It assesses nodule stiffness or displacement depending on the applied force to differentiate malignant from benign thyroid nodules. Objectives: The aim of this study was to evaluate the diagnostic utility of real time US elastography in the differentiation the benign from malignant thyroid nodule. Patients and methods: A cross-sectional was carried out on 40 patients attending ultrasound unit/radiology in Al-Imamein Al-Kadhimein Medical city in Baghdad/Iraq from September 2018 to August 2019. All patients were examined by B-mode ultrasound, color Doppler, and real-time elastography by Voluson-E6 Ultrasound machine. Final diagnoses obtained from histological and/or cytological evaluation. Results: The mean age of 40 patients was 43.7±11.7 years with the range of 25-70 years. 28 (70%) of them were female and 12 (30%) were male. Of the 40 lesions 34 (85%) were benign and 6 (15%) were malignant lesions. Malignant thyroid nodules were significantly hypoechoic, with irregular margin, taller than wider, showed microcalcification and exhibited a significant increase in vascularity with varying rate of sensitivity and specificity. Orientation (taller than wider) was the most ultrasound predictive pattern of malignancy with sensitivity, specificity, and accuracy of 66.7%, 100%, and 92.5% respectively. The mean strain ratio of all nodules was 2.7±2.1 ranged 0.4-13.5 with significant result. The optimal strain ratio cutoff value was >2.5 and showed to have a sensitivity of 100%, specificity 88.2%, positive predictive value 67%, negative predictive value 100%, and accuracy rate 90%. Conclusion: Elastosonography can assist in the differential diagnosis of malignant and benign thyroid nodules, as strain elastosonography improve the diagnostic performance in differentiating the benign and malignant thyroid nodule. strain ratio is higher in malignant than benign nodules. [ABSTRACT FROM AUTHOR]