Background and Rationale:

High-definition white light endoscopy (WLE) remains the standard-of-care for evaluating early laryngeal lesions, providing high-resolution surface and color information. However, WLE has well-recognized limitations. Early dysplasia may lack clear surface changes, while benign inflammatory lesions can mimic malignancy, resulting in sensitivity values as low as 51% in some studies.

The quintessential clinical dilemma is vocal fold leukoplakia—a descriptive term encompassing a wide histopathological spectrum, from benign hyperkeratosis to invasive squamous cell carcinoma (Piazza et al., 2010). Because WLE cannot reliably predict histopathological severity, management remains highly controversial. Some clinicians advocate routine surgical biopsy due to the risk of occult carcinoma, while others support conservative observation in low-risk cases (Peretti et al., 2017). This uncertainty results in a significant healthcare burden driven by repeated surveillance, unnecessary biopsies, and the risk of delayed diagnosis.

Role of Narrow Band Imaging (NBI):

NBI has emerged as a critical adjunct by enhancing the visualization of intraepithelial papillary capillary loops (IPCLs), thereby improving the detection of neoplastic vascular patterns (Piazza and Peretti, 2012). Recent literature demonstrates a strong correlation between NBI vascular patterns and histopathological outcomes, improving diagnostic precision and aiding in the prediction of malignant transformation in leukoplakia (Lin et al., 2020; Pietruszewska et al., 2021).

Despite its growing acceptance, NBI is not a panacea. It remains highly dependent on operator expertise and is subject to diagnostic pitfalls, particularly in post-radiotherapy mucosa and lesions with deep submucosal extension.