Aspiration pneumonia is a major cause of death in patients on nasogastric tube (NGT) feeding. This study aimed to evaluate the oropharyngeal dysphagia and stratify risk of pneumonia in patients undergoing NGT feeding. The study included patients on NGT feeding who underwent UGI endoscopy at Tri-Service General Hospital, Taiwan. Endoscopy was performed to examine the pharyngolaryngeal region. The severity of oropharyngeal dysphagia was evaluated according to the visualized amount and location of pooling of secretions in the pharyngolaryngeal region; 60 patients showed absent or minimal amount of secretions (control group), 14 patients showed moderate-to-large amounts of secretions filling the pyriform sinus (pharyngeal group), and 27 patients showed secretions entering the laryngeal vestibule (laryngeal group). Demographic data and occurrence of pneumonia were analyzed. The incidence of pneumonia was highest in the pharyngeal group (4.2±3.6 episodes/person-years), followed by the laryngeal (2.6±2.2 episodes/ person-years) and control groups (1.7±3.8 episodes/person-years) (p=0.042). Multivariable regression showed significantly higher risk of pneumonia in the pharyngeal (adjusted odds ratio=2.7, 95% CI, 2.4-2.8, p<0.001) and laryngeal (adjusted odds ratio=2.0, 95% CI, 1.7-2.4, p<0.001) groups. The cumulative incidence rate of pneumonia was significantly higher in the laryngeal and pharyngeal groups than in the control group (log rank test, p<0.001). Endoscopic pharyngolaryngeal observation can evaluate the oropharyngeal dysphagia. Visual evidence of oropharyngeal dysphagia increase the risk of pneumonia in patients on NGT feeding.