Endosonography (EUS) has emerged as a pivotal diagnostic tool in assessing lymphadenopathy, offering a minimally invasive approach with high-resolution imaging and the ability to perform fine-needle aspiration (FNA). This review critically evaluates the role of endosonography in differentiating malignant from benign lymph nodes, focusing on key ultrasonographic features, including size, shape, border characteristics, echogenicity, and vascular patterns. The integration of advanced technologies, such as contrast-enhanced EUS and elastography, has further enhanced diagnostic accuracy. Additionally, the review explores the role of EUS-FNA in obtaining cytological samples for histopathological analysis, addressing its sensitivity, specificity, and limitations. Current evidence indicates that while certain ultrasonographic features strongly suggest malignancy, definitive differentiation often relies on tissue diagnosis. This article highlights the strengths, challenges, and future directions of endosonography in lymph node evaluation, emphasizing its role in guiding clinical decision-making and improving patient outcomes.