Background: This study aims to assess the value of narrow band imaging (NBI) endoscopy in the diagnosis of pharyngo-laryngeal lesions and to demonstrate the validity of a new NBI-based classification of their vascular pattern. Methods: In 2009-2011, 248 pharyngo-laryngeal lesions underwent NBI-endoscopic evaluation. NBI findings were classified into 5 types according to the Ni classification and were compared with histopathological reports. Sensitivity, specificity, accuracy, positive and negative predictive values were calculated. Results: Sensitivity, specificity, accuracy, positive and negative predictive values were 97.4\%; 84.6\%, 92.7\%, 91.6\% and 95.1\% respectively. Ninety-eight\% of histologically malignant lesions corresponded to type V endoscopic pattern, while 84.8\% of the non neoplastic lesions corresponded to a type I-IV pattern. Conclusions: the NBI ability to detect changes in the mucosal microvasculature can be useful for distinguishing non-malignant from malignant lesions. An internationally accepted NBI-endoscopic classification may contribute to the further definition of the diagnostic validity of this technique. Head Neck, 2013.