Head and neck cancer treatment: surgery, radiotherapy and chemotherapy in principle

Topic

Early head and neck cancer is treated with one method (surgery or radiotherapy); advanced cancer needs combined treatment.

Updated Nov 12, 2026

Key points

Early stage (I to II): single modality, surgery (transoral laser or robotic surgery, partial laryngectomy) or radiotherapy.
Advanced stage (III to IV): surgery plus adjuvant radiotherapy, or concurrent chemoradiotherapy with cisplatin for organ preservation (larynx, hypopharynx, oropharynx).
Total laryngectomy remains first-line for bulky T4 laryngeal cancer and is the standard salvage after radiotherapy failure; it leaves a permanent tracheostoma.
Radical neck dissection removes levels I to V with the sternocleidomastoid, internal jugular vein and accessory nerve; modified radical spares at least one of them; selective removes only some levels.
Cetuximab (anti-EGFR antibody) can be given with radiotherapy when cisplatin is not possible; typical side effect: acneiform rash.
Nasopharyngeal carcinoma is treated mainly with radiotherapy (with chemotherapy when advanced), not with surgery.

What it is

Head and neck squamous cell carcinoma is treated by a multidisciplinary team that weighs cure against speech, swallowing and breathing. The stage (TNM), the site and the patient's health decide the plan. Early tumours (stage I and II) are usually treated with a single modality, surgery or radiotherapy, with similar control rates in many sites. Advanced tumours (stage III and IV) need combined treatment: surgery followed by radiotherapy, with chemotherapy added for high-risk features, or concurrent chemoradiotherapy with cisplatin that aims to preserve the organ. The neck is treated together with the primary. For recurrent or metastatic disease the options are platinum chemotherapy, cetuximab and immune checkpoint inhibitors. This page explains the principles; side effects and follow-up are on the page about life after treatment.

Key facts

Elective (prophylactic) neck dissection or neck irradiation is offered when the risk of hidden neck metastasis is more than about 15 to 20 %.
Adjuvant chemoradiotherapy after surgery is added for high-risk pathology, such as positive margins or extranodal extension.
After chemoradiotherapy for advanced neck disease, PET-CT surveillance can avoid a planned neck dissection when the response is complete.
Voice after total laryngectomy: tracheoesophageal puncture with a voice prosthesis, oesophageal speech or an electrolarynx.
Cisplatin is ototoxic and nephrotoxic: baseline and follow-up audiometry and renal function are needed.
HPV-positive oropharyngeal cancer has a better prognosis than HPV-negative disease and its own staging.

Structure

Surgery: transoral (laser, robotic), open resection with reconstruction (local, regional or free flaps), laryngectomy (partial or total), neck dissection.
Radiotherapy: external beam, given in daily fractions over several weeks; intensity-modulated radiotherapy spares the parotids and other normal tissue.
Chemotherapy: concurrent with radiotherapy as a radiosensitiser (cisplatin), induction before definitive treatment in selected cases, palliative for recurrent or metastatic disease.
Targeted and immune therapy: cetuximab; anti-PD-1 antibodies (pembrolizumab, nivolumab) for recurrent or metastatic disease.
Support: dental assessment before radiotherapy, nutrition (sometimes a feeding tube), speech and swallowing therapy, smoking and alcohol cessation, palliative care.

The usual treatment logic

Situation	Usual approach	Function goal
Early glottic cancer (T1 to T2)	Radiotherapy or transoral laser surgery	Keep a good voice
Early oral cavity cancer	Surgery with neck management	Keep speech and swallowing
Advanced larynx or hypopharynx, larynx still working	Concurrent chemoradiotherapy (organ preservation)	Keep the larynx
Bulky T4 larynx or failure after radiotherapy	Total laryngectomy ± neck dissection and adjuvant radiotherapy	Cure; voice rehabilitation afterwards
Advanced oral cavity cancer	Surgery with reconstruction, then radiotherapy ± chemotherapy	Cure with reconstruction
Nasopharyngeal carcinoma	Radiotherapy, with chemotherapy when advanced	Avoid difficult skull base surgery
Recurrent or metastatic disease	Platinum chemotherapy, cetuximab, anti-PD-1 immunotherapy; palliative care	Survival and symptom control

In clinical practice

Treatment starts only after biopsy and full staging; decisions are made in a tumour board.
Dental extraction of unhealthy teeth is done before radiotherapy to reduce the risk of osteoradionecrosis.
A patient with a permanent tracheostoma breathes only through the neck: oxygen and emergency ventilation go through the stoma.
Stopping smoking improves the response to radiotherapy and lowers the risk of a second cancer.

Next step / Initial management

Workup before treatment: biopsy of the primary, CT or MRI of the primary and neck, chest imaging or PET-CT for advanced disease, dental review, nutrition and swallowing assessment, baseline audiometry if cisplatin is planned.
First-line management follows the stage: single modality for early disease, combined modality for advanced disease, decided by the multidisciplinary team.
Refer urgently (within two weeks, cancer pathway of the health insurer) any patient with suspected head and neck cancer to otolaryngology or head and neck surgery; same-day referral if there is stridor or inability to swallow.
During and after treatment, refer early to speech and swallowing therapy, nutrition, dentistry and palliative care as needed.

Test yourself

Think of the answer, then tap the question to see it.

A 60-year-old smoker has a T1 glottic carcinoma with a mobile vocal fold. What are the standard options?

Single-modality treatment: radiotherapy or transoral laser surgery, with similar control and a good chance of preserving the voice.

Which three non-lymphatic structures are removed in a classic radical neck dissection?

Sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve (with lymph node levels I to V).

A patient with advanced laryngeal cancer wants to keep his larynx. What is the standard non-surgical option?

Concurrent chemoradiotherapy with cisplatin (organ preservation), keeping total laryngectomy for persistent or recurrent disease.

A patient cannot receive cisplatin because of kidney disease. Which drug can be combined with radiotherapy, and its typical side effect?

Cetuximab, an anti-EGFR antibody; its typical side effect is an acneiform rash (also infusion reactions).

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Elsewhere in DurgiPedia

Cancer immunotherapy: checkpoint inhibitors, CAR-T and vaccines

Connections

In Pharmacology1

Cisplatin

← All of ENT

Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: Laryngeal Cancer (StatPearls Publishing (NCBI Bookshelf), 2024); Total Laryngectomy (StatPearls Publishing (NCBI Bookshelf), 2023); Radical Neck Dissection (StatPearls Publishing (NCBI Bookshelf), 2023); Oropharyngeal Squamous Cell Carcinoma (StatPearls Publishing (NCBI Bookshelf), 2023); Cetuximab (StatPearls Publishing (NCBI Bookshelf), 2023); Adverse Effects of Radiation Therapy (StatPearls Publishing (NCBI Bookshelf), 2025); Laryngeal Cancer Treatment (PDQ), Health Professional Version (National Cancer Institute (NCI), 2025).

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Representative model, for educational purposes only.