Objective To investigate the value of high frequency ultrasound combined with shear wave elastography (SWE) in the differential diagnosis of benign and malignant thyroid nodules in Hashimoto"s thyroiditis (HT). Methods 35 cases of HT patients with thyroid malignant nodules admitted to our hospital from September 2021 to July 2023 were retrospectively collected and included into group A; 35 patients with HT combined with benign thyroid nodules were included in group B. All patients were confirmed by surgical or pathological biopsy results. The high-frequency ultrasonic signs and shear-wave elastic imaging of the two groups were analyzed statistically. The high-frequency ultrasonic parameters and the mean value of Young"s modulus were compared between the two groups. By comparing the diagnostic results of different examination methods, the diagnostic efficiency was analyzed. Results The sensitivity of combined diagnosis was 94.29%, higher than that of single diagnosis (71.43%, 71.43%), and the missed diagnosis rate was 5.71%, lower than that of single diagnosis (28.57%, 28.57%) (P < 0.05). The mean value of Young"s modulus in group A was significantly higher than that in group B (P < 0.05). The proportion of blurred boundary, uneven reinforcement, micro-calcification and abundant blood vessels in nodules in group A was higher than that in group B, and the proportion of morphological rules was lower than that in group B (P < 0.05). Conclusion The combined diagnosis of high frequency ultrasound and SWE technology can significantly improve the diagnostic sensitivity and reduce the rate of missed diagnosis, which is conducive to early diagnosis of nodule properties in the background of HT, and has important significance for improving the prognosis of patients.