A Risk‐Adapted Approach for Elective Neck Dissection in Salvage Total Laryngectomy: Revisiting the Role of Tumor Subsite and Occult Nodal Disease

Background The role of elective neck dissection (END) during salvage total laryngectomy (STL) in clinically node‐negative (cN0) patients remains controversial due to variable risks of occult nodal metastasis and surgical morbidity. Methods We conducted a multicenter retrospective study of 178 cN0 patients undergoing STL after radiotherapy (RT) or chemoradiotherapy (CRT). Rates of occult nodal disease, survival outcomes, and predictive factors were analyzed. Results Occult nodal metastases were found in 19.7% of cases, highest in hypopharyngeal (35.7%) and supraglottic (24.5%) tumors. Tumor subsite and lymphovascular invasion were independent predictors of nodal positivity, while prior chemotherapy reduced risk. Patients with occult nodal disease had significantly worse three‐year overall and disease‐specific survival. Conclusions A risk‐adapted approach to END in STL is recommended, particularly for supraglottic and hypopharyngeal tumors. Routine END may be unnecessary in low‐risk subsites like glottic tumors. Prospective studies are needed to refine management strategies.