One of the most important prognostic factors in head and neck squamous cell carcinoma is to control and manage regional metastasis. A few studies reported that real-time elastography (elastography) was used in the examination of lymph node metastasis. The purpose of the present study was to evaluate the efficacy of elastography in order to diagnose cervical lymph node metastasis in head and neck cancer. Our study included 253 lymph nodes in 37 patients with head and neck squamous cell carcinoma who underwent neck dissection from October 2007 to December 2008. Grade of the elastographic findings was determined by the hardness of the lymph node based on Furukawa's classification. The patterns of images were compared with the histopathological diagnosis obtained by neck dissection. Elastographic pattern 3 and 4 were considered metastatic. The precision of diagnosis was as follows: sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of elastography were 81.0%, 90.8%, 88.5%, 72.3% and 94.1%, respectively. The combined evaluation of elastography and ultrasonography, PPV and NPV were improved to 95.6% and 95.6%, respectively. The combination of elastography with ultrasonography might improve the precision of diagnosis of cervical lymph node metastasis in head and neck squamous cell carcinoma.