Nasopharyngeal carcinoma (NPC) is a unique subtype of head and neck cancer that is endemic to Southern China and Southeast Asia. Due to the concealed location and intrinsic invasiveness of this disease, majority of NPC patients are diagnosed with advanced stages (III and IV) and poor prognosis. Chemoradiotherapy resistance is a major problem for NPC patients, leading to incomplete local elimination, recurrence and metastasis. Therefore, it is of great significance to seek novel biomarkers and effective therapeutic regimen for clinical management of this deadly cancer. Exosomes are tiny membrane vesicles with a lipid bilayer secreted by most cells in the body, which are widely distributed in various body fluids. They are functionally active in different physiopathological process by carrying and transmitting important signal molecules such as miRNA, mRNA, protein, lipid, etc. Exosomal miRNAs play an important role in tumorigenesis and development of NPC. They are extensively involved in NPC cell proliferation, migration, invasion, neovascularization, radiotherapy resistance and the regulation of tumor immune microenvironment through intercellular communication and control of gene expression. Moreover, exosomal miRNAs can be used as valuable biomarkers for early diagnosis and therapeutic targets of NPC.