Subepithelial esophageal lesions (SELs) constitute approximately 30% of upper gastrointestinal submucosal lesions, with a rising incidence in recent years. Prognostic heterogeneity among SELs directly dictates clinical decision-making regarding therapeutic strategies and surveillance protocols. The absence of pathognomonic symptoms and standardized diagnostic-therapeutic algorithms continues to challenge the clinical management of SELs. Innovations in endoscopic ultrasound (EUS) technology have driven transformative advances in the diagnosis and treatment of SELs. Novel modalities including quantitative elastography and contrast-enhanced harmonic EUS (CH-EUS) have enhanced noninvasive differentiation, while US capsule endoscopy (USCE) and EUS-AI may facilitate primary healthcare and standardized diagnostic-therapeutic practices. This review synthesizes the recent progress in these domains.