Surgeon-controlled real-time ultrasound (US) is a new adjunct in the management of patients with thyroid malignancy. The introduction of US as a routine evaluation tool has increased the recognition of nonpalpable thyroid cancers and cervical lymph node metastases. We report our experience and the change in management of patients with thyroid cancer due to the use of US. We reviewed the records of all patients undergoing neck operations for thyroid cancer since 2002. US was performed by a surgeon preoperatively in all patients and intraoperatively when non-palpable cervical lymph nodes were present. Suspicious nonpalpable thyroid nodules underwent US-guided fine-needle aspiration (FNA) for cytology. Seventy-two patients underwent operations for thyroid cancer. US influenced the management in 57 per cent (41/72) of patients. US was useful in 1) identification and guidance for the FNA of nonpalpable cancers in 28 per cent (20/72), 2) identification of nonpalpable nodules in the contralateral lobe in 38 per cent (27/72), 3) preoperative diagnosis of nonpalpable metastatic lymph nodes in 24 per cent (17/72), and intraoperative guidance for their excision. Surgeon-performed US changed and enhanced the pre- and intraoperative management in more than half the patients with thyroid cancer.