Objective: To assess the diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in elderly patients with hilar and mediastinal lesions. Methods: A total of 206 patients (≥ 65 years of age) hospitalized in the Department of Respiratory and Critical Care Medicine of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine were enrolled, and all had hilar or mediastinal lymphadenopathy, and/or paratracheal and bronchial masses detected on CT or PET-CT, and all had definite histopathologic findings (including percutaneous lung biopsy, thoracoscopy, open thoracic surgery, and superficial lymph node biopsy). The diagnostic efficacy of EBUS-TBNA was assessed by comparison with the pathologic findings as the gold standard and the cases with missed diagnosis were analyzed. Results: Of the 206 patients, 61 lesions had paratracheal and/or bronchial lesions aspirated, and 225 groups of lymph nodes aspirated via EBUS-TBNA. Pathological examination revealed that 151 patients had malignant disease and 55 patients had benign disease. EBUS-TBNA identified 140 cases out of 151 malignant tumors and 50 cases out of 55 benign lesions, respectively. The diagnostic sensitivity, specificity of EBUS-TBNA for malignant tumors were 92.7%, 100%, respectively and the missed diagnosis rate was 7.8%. The diagnostic sensitivity and specificity of EBUS-TBNA for benign lesions were 90.9%, 100%, respectively, and the missed diagnosis rate was 9.1%. The major causes for missed diagnosis included small lesions (diameter <1 cm), small tissue sample or small number of tissue samples to be examined. Conclusions: EBUS-TBNA is a safe and effective approach with high diagnostic sensitivity and specificity for elderly patients with hilar and mediastinal lesions. For lesions with negative result of EBUS-TBNA but lesion with average length or diameter <1 cm, missed diagnosis should be awared of.