The purpose of this study was to evaluate the frequency of echogenic foci with comet-tail artifact in histologically proven thyroid nodules, and to determine the types of echogenic foci with comet-tail artifact that are associated with malignancy. We retrospectively analyzed the sonographic findings of echogenic foci with comet-tail artifact, present in thyroid nodules in 63 patients who underwent surgery for thyroid nodules at our institution between January 2016 and September 2016. The sonographic findings (appearance and background of echogenic foci, shape of comet-tail artifact) in benign and malignant nodules were compared. Seventy-one (7.4%) nodules with ultrasound finding of echogenic foci with comet-tail artifact were encountered in 962 thyroid nodules of 556 patients; 25 of these were benign, and 46 were malignant. Among the echogenic foci with comet-tail artifact categories, those (11/11, 100%) freely distributed in cystic components were all in benign nodules, whereas those (48/67, 71.6%) any part of echogenic foci or comet-tail artifact associated with solid components, were more common in malignant nodules (P < 0.001). There was no statistically significant difference in the appearance of echogenic foci and the shape of comet-tail between the benign and malignant nodules (P = 0.139, P = 0.626, respectively). Echogenic foci with comet-tail artifact freely distributed in cystic component may predict a benign nodule; those associated with solid components cannot be considered a benign finding.