Objective To investigate the feasibility and perioperative safety of microwave ablation for the elderly with benign thyroid nodules under ultrasound guidance. Methods A retrospective analysis was carried out on 471 elderly over 60 years old with benign thyroid nodules (totally 1000 nodules) who underwent microwave ablation under the ultrasound guidance in our department from July 2009 to October 2015. Intraoperative and postoperative adverse reactions and corresponding treatment measures were recorded. The ablation range was assessed by contrast-enhanced ultrasound examination after operation. Results Ultrasound guided percutaneous microwave ablation was successfully performed on all the 471 patients under local anesthesia. Among them, 453 patients with 979 nodules were ablated completely, and 18 patients with 21 nodules were ablated mostly because nodules grew behind the sternum. The ablation time for single nodule was (150±103)s. After the end of ablation, contrast enhanced ultrasound examination showed that the volume of no contrast agent filling area was (8.45±16.26)cm3, which had no significant difference with the preoperative mean volume of nodules ［(8.66±15.61)cm3, P>0.05］. This indicated that tumor tissues were completely ablated, with no obvious residual, and the nodules achieved complete ablation. All patients had good tolerance, and no adverse effects and pain terminated the surgical treatment. There were 432 patients having pain grade of 0-5. After operation, 1 case suffered from left heart failure, and the other one from bronchial spasm. No severe complications were found in the subjects. Conclusion Percutaneous microwave ablation under ultrasound guidance is a safe and effective approach for the elderly with benign thyroid nodules. It is worthy of promotion in clinical practice.