Background Ultrasound is a minimally invasive diagnostic method that enables real-time sampling of the hilar and mediastinal lymph nodes. Aim To evaluate the role of spectral Doppler using endobronchial ultrasound (EBUS) in the differentiation of mediastinal lymph node lesions. Patients and methods The study was conducted at the Pulmonology Department, Faculty of Medicine, Cairo University and it was conducted between February 2023 and March 2024. The study was performed on 32 patients who had been referred to the Chest Department, Kasr El-Aini Hospital for clinical assessment; all of them have computed tomography evidence of mediastinal lymphadenopathy. All patients were subjected to history taking including age, sex, smoking, and assessment of symptoms. Clinical examination includes cervical lymph node examination, examination of neck veins and local chest examination. Computed tomography chest with i.v. contrast. Routine laboratory investigations (CBC, PT, PC, INR, liver functions, and renal functions). Ultrasound examination using spectral Doppler ultrasound and guided intervention (EBUS–TBNA) to lymph node through EBUS. Results Features of spectral Doppler using EBUS have a role in differentiating between malignant and benign mediastinal lymphadenopathy. These features include pulsatility index, resistive index, peak systolic velocity, end-diastolic velocity, lymph node texture, architecture, borders, invasion of surrounding structure and capsule, and vascularity. All are used as predictors that contribute to diagnosing malignant and benign mediastinal lymphadenopathy. Conclusion Spectral Doppler is a form of imaging using EBUS that has a role in differentiating between malignant and benign mediastinal lymphadenopathy and contributes to its diagnosis.