Summary The aim of the study was to investigate the novel endoscopic findings in nasopharyngeal carcinoma (NPC) under narrow-band imaging (NBI) and to determine the reliability of screening NPC by NBI. A total of 79 adults underwent nasopharyngeal biopsy. We proposed five distinctly different findings that need to be examined by NBI: Type I: brownish spots, Type II: irregular microvascular pattern (IMVP), Type III: light crests, Type IV: side-difference, Type V: presence of either IMVP or side-difference, of which last three (Type III–V) were a new concept. The results of NPC diagnosis by detecting NBI Type V pattern, the false positive, false negative, sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 6.7%, 2.9%, 97.1%, 93.3%, 91.7%, 97.7%, and 94.9%, respectively. On the other hand, there was a higher prevalence of Type I and IV patterns in T1 category NPC. The nasopharyngeal endoscopy coupled with NBI was able to provide a rapid, convenient, and highly reliable screening for high-risk populations.