Objective To analyze the clinical and pathological features of thyroid nodule fine-needle aspiration biopsy (FNAB) in the elderly. Methods Clinical and pathological data of 382 elderly patients receiving thyroid nodule FNAB in our hospital during May 2005 to December 2011 were collected and retrospectively analyzed. Cytopathological diagnosis of FNAB was classified as nondiagnostic/unsatisfactory, benign, atypia of undetermined significance/follicular lesion (AUS/FL), follicular neoplasm (FN), suspicious malignancy and malignancy according to the Bethesda System for Reporting Thyroid Cytopathology 6 (BSTC6). Clinical data included age, sex, thyroid function test and thyroid ultrasound findings. Results Of 382 thyroid nodule FNAB, 14.7% (56/382), 71.7% (274/382), 3.4% (13/382), 4.7% (18/382), 2.1% (8/382) and 3.4%(13/382) were classified as nondiagnostic, benign, AUS/FL, FN, suspicious malignancy, and malignant, respectively. Among the 355 patients receiving thyroid function test, 70.1% (249/355) were identified as euthyroid and 29.9% (106/355) had thyroid dysfunction. Conclusion Most elderly patients have benign lesions of thyroid nodule, and preoperative FNAB can avoid the surgical treatment for thyroid nodules. Elderly patients with thyroid nodules have a high risk of thyroid dysfunction, and it is very important for them to take thyroid function test.