Medical ultrasound scanners are typically calibrated to the soft tissue average of 1540 m s −1 . In regions of different sound speed, for example organs and tumours, the B-mode image then becomes a distortion of the true tissue cross-section, due to the misrepresentation of length and refraction. We develop a ray model to predict the geometrical distortion of a general elliptical object with atypical speed of sound, and quantify the ensuing image distortion as a function of the key parameters, including the speed of sound mismatch, the object size and its elongation. Our findings show that the distortion of area can be significant, even for relatively small speed of sound mismatches. Our findings are verified by ultrasound imaging of a test object.