Ultrasonography (US) and the new applications US elastography (USE) and contrast-enhanced US (CEUS) are used in the screening of thyroid nodules, for which fine-needle aspiration biopsy (FNAB) is the best single diagnostic test. The aim of the study was to compare the sensitivity, specificity, positive predictive value (PPV), and accuracy of the four examinations in nodules with cytological and histological diagnoses. The study used data from US, FNAB, USE (elasticity (ELX 2/1) index), and CEUS (Peak index and time to peak (TTP) index) evaluated in 73 thyroid nodules in 63 consecutive patients likely to undergo surgery. Cytological-histological correlation was available for 38 nodules. No correlation emerged between nodule size and cytological results. A significant (P=0.03) positive correlation between cumulative US findings and cytological results was found. In addition, significant correlations between cumulative US findings and cytology (P=0.02) and between cumulative US findings and histology (P<0.0001) were found. US showed the best specificity and PPV, and FNAB the best sensitivity. There was no significant difference in the ELX 2/1 index, Peak index, or TTP index among nodules subdivided according to cytological scores. No significant correlation was found between ELX 2/1 index, Peak index, and TTP index, on the one hand, and nodule size, US cumulative findings, cytology, and histology on the other hand. The sensitivity of the ELX 2/1 index was high, but its specificity was very low. The accuracy and PPV of USE were lower than those of the other procedures. Only the correlation between Peak index and cumulative US findings reached a value close to significance. Our ultimate aim is to minimise unnecessary thyroidectomy. US and FNAB continue to play a central diagnostic role. The use of a US score showed high specificity and PPV. The specificity of FNAB was low in this selected series because of the numbers of indeterminate cytological responses. USE and CEUS are innovative techniques that need to be standardized. The ELX 2/1 index, Peak index, and TTP index seem to be unrelated to histology. The best statistical data on USE and CEUS concerned their sensitivity and PPV, respectively. At present, USE and CEUS are too time-consuming and of limited utility in selecting patients for surgery.