Background: Transnasal videoendoscopy (TVE) is the standard of care when staging pharyngolaryngeal lesions. This prospective study determined if preoperative TVE improves the prediction of difficult videolaryngoscopic intubation in adults with expected difficult airway management in addition to the Simplified Airway Risk Index (SARI). Methods: 374 anesthetics were included (252 with preoperative TVE). The primary outcome was a difficult airway alert issued by the anesthetist after Macintosh videolaryngoscopy. SARI, clinical factors (dysphagia, dysphonia, cough, stridor, sex, age and height) and TVE findings were used to fit three multivariable mixed logistic regression models; least absolute shrinkage and selection operator (LASSO) regression was used to select co-variables. Results: SARI predicted the primary outcome (odds ratio [OR] 1.33; 95% confidence interval [CI] 1.13–1.58). The Akaike information criterion for SARI (327.1) improved when TVE parameters were added (311.0). The Likelihood ratio test for SARI plus TVE parameters was better than for SARI plus clinical factors (p< 0.001). Vestibular fold lesions (OR 1.82; 95% CI 0.40–8.29), epiglottic lesions (OR 3.37; 0.73–15.54), pharyngeal secretion retention (OR 3.01; 1.05–8.63), restricted view on rima glottidis <50% (OR 2.13; 0.51–8.89) and ≥50% (OR 2.52; 0.44–14.56) were concerning. Conclusion: TVE improved prediction of difficult videolaryngoscopy in addition to traditional bedside airway examinations.