Background: Shear ware Elastography is a new diagnostic tool for differentiating benign and malignant thyroid nodules . The objective of this study was to evaluate the value of shear wave elastography (using the E1/E2 ratio) in differentiating benign thyroid nodules from malignant ones aiming to have a cutoff of values as compared with the results of FNAB/tissue pathology under the ACR-TIRADS guidelines. Methods: We evaluated 100 suspicious nodules found on 100 consecutive patients whom were referred from internal medicine and general surgery clinics between the periods of 8/2022 To 5/2023 for characterization of their clinically suspected nodular goiter. Patients had FNAB according to ACR-TIRADS guidelines to characterize their clinically proven single or multinodular goiter. Elastography ratio results were compared with the results of fine needle aspiration biopsy or tissue pathology Results: From the studied one hundred nodules, 68 of which were benign and 32 were malignant. The Median of E1 values were 61.6 with interquartile range from 26.6 to 90.4 for benign nodules and 144.2 with interquartile range from123.3 to 181.5 for malignant ones. The median of E1/E2 ratio was 0.34 with interquartile range from 0.22 to 0.65 for benign nodules and it was 0.09 with interquartile range from 0.07 to 0.16 for malignant nodules. ROC curve for E1/E2 ratio to predict benign and malignant thyroid lesions. Cut-off ≤ 0.15 predict malignant lesions. Conclusions: Shear wave Elastography ratio could be considered as reliable and valuable tool in differentiation between benign and malignant thyroid nodules with or without conventional ultrasound.