Thyroid punctate strong echoes may be microcalcifications, suggesting possible thyroid cancer, but they may also be comet tail pseudoimages or of uncertain significance. The three categories of thyroid punctate echoes include microcalcifications, comet tail pseudoimages, and unclear significance. Microcalcifications are punctate echoes <1 mm with or without posterior acoustic shadowing, which correspond to gravel bodies on pathologic examination and are malignant signs, suggesting the possible presence of papillary thyroid carcinoma. Comet tail artifacts, which refer to punctate echoes with posterior acoustic shadows, are mostly due to condensed colloid calcification and are benign. Some punctate echoes are difficult to categorize as benign or malignant, and are of uncertain significance. It is recommended that patients with punctate echoes be seen promptly for further investigation and treatment based on other descriptions in the ultrasound and other imaging reports, as well as other tests such as thyroid function and antibodies.