Abstract : Background: Image-guided fine needle aspiration cytology (FNAC) is emerging as an important diagnostic tool in the evaluation of thyroid swellings.Aim: This study aims to assess the efficacy of ultrasound (US)-guided FNAC combined with 'The Bethesda system' of reporting as a primary screening test for all thyroid lesions.Settings and Design: A prospective cohort study was made and all the US-guided FNACs done were followed up to find out the histopathological diagnoses wherever surgery was done.Materials and Methods: In all, 1050 patients who underwent US-guided FNAC were studied during a period of 1 year. Age, sex, cytological features, and histological diagnoses were analyzed. Statistical analyses of all the findings were done to derive conclusions.Results: Of the 1050 patients, only 10.5% underwent surgery. Higher than expected rate (as per the Bethesda system) of malignancy was noted with the so-called grey zone lesions. The test results revealed a high level of sensitivity, specificity, and diagnostic accuracy.Conclusion: The study showed that The Bethesda System of Reporting Thyroid Cytology provides effective communication between clinician and pathologists thereby enabling clear management strategies. We also concluded that US-guided FNACs offer better results compared with palpation-guided FNACs.