Introduction The palatine tonsils are lymphatic tissues located in the lateral oropharynx, with a rich blood supply from branches of the external carotid artery and venous drainage through the peritonsillar plexus. Narrow-band imaging (NBI) is a novel optical imaging technique using 415 nm and 540 nm wavelengths to enhance visualization of superficial and subepithelial vessels, respectively. This study aims to evaluate preoperative tonsillar vascularity using NBI and correlate it with intraoperative bleeding risk. Aim To assess the vascularity of the tonsil preoperatively using NBI and correlate it with the quantity of intraoperative bleeding. Methodology This prospective cohort study included 30 patients diagnosed with tonsillitis from January 30, 2022, to January 30, 2023, at a tertiary care center in South India. Inclusion criteria were patients aged 5-35 years with confirmed tonsillitis requiring surgical intervention. Patients underwent NBI under topical anesthesia and were graded according to the IPAB pattern classification. Intraoperative blood loss was assessed and correlated with preoperative NBI grades. Statistical analysis was performed using SPSS software. Results - Acute Tonsillitis: Pre-treatment: 70% of patients had a moderate IPCL pattern. - Post-treatment: Significant reduction in IPCL pattern (p = 0.005), with 60% showing improvement. - Chronic Tonsillitis: - 60% had minimal IPCL patterns. - Significant correlation between NBI grading and intraoperative bleeding (p < 0.001). - Intraoperative Blood Loss: - Higher NBI grades were associated with increased bleeding. The duration of surgery was longer for acute tonsillitis (60-120 minutes) compared to chronic tonsillitis (30-60 minutes). Discussion NBI proved effective in assessing tonsillar vascularity and predicting intraoperative bleeding risk. Preoperative antibiotics reduced the NBI grade and subsequent bleeding in acute tonsillitis cases. The study supports the use of NBI in improving perioperative outcomes by minimizing blood loss during tonsillectomy. Conclusion NBI is a valuable tool for preoperative assessment of tonsillar vascularity, helping to predict and manage intraoperative bleeding risk. Its implementation can reduce morbidity and complications associated with tonsillectomy.